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Full text of "United States Navy Medical News Letter Vol. 44 No. 7, 2 October 1964"

NAVMED P-5088 




Vol. 44 



Friday, 2 October 1964 



No. 7 




CONTENTS 



FEATURE ITEM 

Operation SEA ORBIT 1 

MEDICAL ABSTRACTS 

FROSTBITE (Part I) 2 

"To Walk on Frozen Toes" _- 5 

Urologic Diagnosis 7 

FROM THE NOTE BOOK 

Surgeon General Praises Chief Atzert 10 

NavPers I0707-A Discontinued 10 

Senior Foreign Military Medical Officers Convene 

at U. S. Naval Medical School 10 

Post Residency Assignments 12 

APhA Military Section Achievement Award 12 

Society of Military Otolaryngologists 12 

Preparatory School Scholarships for Young Men 

Wishing to Enter the U. S. Naval Academy 12 

DENTAL SECTION 

Case of Erythema Multiforme. _ . 13 

Professional Notes 14 



OCCUPATIONAL MEDICINE 

Federal Employees Occupational Health Service 

Program 17 

The Concept of Biological Variation in 

Audiometric Reference Levels ■_ 20 

Cadmium Poisoning-Calif. 22 

Asbestos Exposure During Naval Vessel Overhaul 22 

RESERVE SECTION 

CAPT Kenneth W. Schenck MC USNR Retires.- 25 
CAPT Curtiss Cummings MC USNR To Report 
As Director, Naval Reserve Division 25 

MISCELLANY 

American Board of Ob-Gyn 26 

The Complete Nightmare 27 

71st Annual Meeting of the Assn of 

Military Surgeons 27 

American Public Health Assn 28 

Inservice Residency Training 26 



United States Navy 
MEDICAL NEWS LETTER 



Vol. 44 



Friday, 2 October 1964 



No. 7 



Rear Admiral Edward C. Kermey MC USN 
Surgeon General 

Rear Admiral R. B. Brown MC USN 
Deputy Surgeon General 

Captain M. W. Arnold MC USN (Ret), Editor 
William A. Kline, Managing Editor 

Contributing Editors 

Aviation Medicine Captain C. E. Wilbur MC USN 

Dental Section Captain C. A. Ostrom DC USN 

Occupational Medicine CDR N. E. Rosenwinkel MC USN 

Preventive Medicine Captain J. W. Millar MC USN 

Radiation Medicine CDR J. H. Schulte MC USN 

Reserve Section Captain C. Cummings MC USNR 

Submarine Medicine CDR J. H. Schulte MC USN 



Policy 

The U.S. Navy Medical News Letter is basically an 
official Medical Department publication inviting the 
attention of officers of the Medical Department of the 
Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to 
medicine, dentistry, and allied sciences. The amount 
of information used is only that necessary to inform 
adequately officers of the Medical Department of the 
existence and source of such information. The items 
used are neither intended to be, nor are they, sus- 



ceptible to use by any officer as a substitute for any 
item or article in its original form. All readers of the 
News Letter are urged to obtain the original of those 
items of particular interest to the individual. 

Change of Address 

Please forward changes of address for the News Letter 
to: Commanding Officer, U.S. Naval Medical School, 
National Naval Medical Center, Bethesda, Maryland 
20014, giving full name, rank, corps, and old and new 
addresses. 



FRONT COVER: USS ENTERPRISE, CVA(N)-65, USS LONG BEACH, CG(N)-9, and USS BAINBRIDGE, 

DLG(N)-25 in formation in Mediterranean Sea. Official U.S. Navy photograph by LT R. R. Conger, USN, 
officially released. 

Members of big E's crew spell out Professor Albert Einstein's mass-energy equation, E— mc : , a practical concept 
which has literally launched this fabulous era of atomic energy. This energy is the source of ENTERPRISE'S pro- 
pulsion power — eight nuclear reactors generating super-heated steam to drive her great turbines and propellers.— 
Editor 



The issuance of this publication approved by the Secretary of the Navy on 4 May 1964. 

U.S. NAVY MEDICAL NEWS LETTER 



FACT SHEET ON 
OPERATION SEA ORBIT* 



Operation SEA ORBIT is scheduled to complete its 
round-the-world cruise on 5 October 1964, proving con- 
clusively the feasibility of operating nuclear surface 
ships over great distances on a self-sustaining basis. 

SEA ORBIT is the first world cruise of surface 
nuclear ships. The task force is made up of USS 
ENTERPRISE (CVAN-65), USS LONG BEACH 
(CLGN-9), and USS BAINBRIDGE (DLGN-25). 
(See front cover of this issue of Medical News Letter.) 
The world cruise has had a dual mission. It has of- 
fered practical experience in operation of nuclear- 
powered warships independent of support ships, a feat 
impractical for conventionally powered ships. Equally 
important, and immediately evident, has been the op- 
portunity to win friends in areas not frequently visited 
by U. S. Navy ships, and to show the world an all 
nuclear element of the world's greatest power for peace. 
Two other world circumnavigations were made by 
U. S. nuclear vessels, both submarines. In 1958, USS 
SKATE (SSN-578) circled the earth in 50 minutes — on 
the 12-mile circle of the North Pole. In 1960, USS 
TRITON (SSN-586) followed Magellan's route around 
the world. TRITON remained submerged for the 
whole voyage. 

In addition to the underway visits held along both 
coasts of Africa, and a port visit to Karachi, Pakistan, 
the week of August 22nd, dignitaries from the following 
cities and nations were scheduled to visit ships of the 
Task Force: 

Fremantle, Australia August 31 

Melbourne, Australia September 3 

Sydney, Australia September 4 

Wellington, New Zealand September 9 

Buenos Aires, Argntina, 

Montevideo, Uruguay September 21 

Sao Paulo, Brazil September 23 

Rio De Janiero, Brazil September 25 

Recife, Brazil September 27 

In-port visits were planned as follows: 
BAINBRIDGE in port at Fremantle, Australia, August 

21 -September 2 
LONG BEACH in port at Melbourne, Australia, Sep- 
tember 3-5 
ENTERPRISE in port at Sydney, Australia, September 

4-7 
LONG BEACH/BAINBRIDGE in port at Wellington, 

New Zealand, September 8-9 
Task Force ONE in port at Rio De Janiero, Brazil, Sep- 
tember 23-25 



News Release, Office of Assistant Secretary of Defense (Public 
Affairs), Washington, D. C. 20301, 22 August 1964. 



Task Force One departed Gibraltar on July 31, under 
the command of RADM Bernard M. Strean USN, with 
an itinerary which included underway visits along both 
coasts of Africa, and underway and in-port of South 
America. 

Dignitaries from nations along the first leg of Task 
Force One's route were flown by ENTERPRISE aircraft 
to the nuclear carrier to be shown the capabilities of the 
Task Force. Aircraft from ENTERPRISE'S carrier air 
wing flew inland for aerial demonstrations for public 
viewing. 

Government officials from Morocco, Senegal, Liberia, 
Ivory Coast, the Union of South Africa, and Kenya, 
were received on board the nuclear flagship, and the 
response was enthusiastic. 

USS ENTERPRISE, the flagship of Task Force ONE, 
was commissioned on November 25, 1961. Built by the 
Newport News Shipbuilding and Dry Dock Company, 
Newport News, Virginia, the 1123 ft carrier can launch 
one of its 100 aircraft each 15 seconds. Its eight nuclear 
reactors can drive the 85,000 ton ship in excess of 25 
knots. ENTERPRISE is commanded by CAPT Fred- 
rick H. Michaelis USN, of Kansas City, Missouri, and 
has a crew of 400 officers, and 4,500 enlisted men with 
the air wing embarked. 

USS LONG BEACH was the world's first nuclear 
powered surface warship to be placed in commission — 
September 9, 1961 . LONG BEACH was built by Beth- 
lehem Steel, Quincy, Massachusetts. The 721 ft, 16,600 
ton cruiser is equipped with TALOS long-range surface 
to air missiles. TERRIER medium range surface to air 
missiles, and ASROC, a surface to underwater anti- 
submarine warfare weapon. LONG BEACH is pow- 
ered by two nuclear power plants. Her crew, com- 
manded by CAPT Frand H. Price USN, of Bethesda, 
Md., consists of 60 officers and 900 enlisted men. 

USS BAINBRIDGE, was commissioned on October 
6, 1962. She was also built by Bethlehem Steel at 
Quincy. The 564 ft, 8,400 ton frigate is armed with 
TERRIER surface to air missiles and ASROC. BAIN- 
BRIDGE's two nuclear reactors can propel it many 
times around the world without additional fuel. CAPT 
Hal C. Castle USN, of Peoria, Illinois, commands 
BAINBRIDGE's 34 officers and 460 enlisted men. 

Aircraft on board ENTERPRISE are attached to 
Carrier Air Wing SIX, CDR T. L. Nielson, of Evanston, 
Wyoming, commanding. Carrier Air Wing SIX, com- 
posed of Fighter Squadrons (VF) 33 and 102; Light 
Attack Squadrons (VA) 64, 65, 66, and 76; Heavy 
Attack Squadron (VAH) 7; In addition, small detach- 
ments from Light Photo Squadron (VFP) 62; All 
Weather Early Warning Squadron (VAW) 12; Heli- 
copter Squadron (HU) 2, and Carrier Transport 



U.S. NAVY MEDICAL NEWS LETTER 



1 



Squadron (VRC 40) are embarked. Aircraft in Carrier 
Air Wing SIX include the F-8 CRUSADER, the F-4B 
PHANTOM II, the A-4E SKYHAWK, the A- IE SKY- 
RAIDER, the A-5 VIGILANTE, the RF-8A CRU- 
SADER the E-1B TRACER, and the UH-2A SEA- 
SPRITE (helicopter). These aircraft represent some of 



the world's newest aircraft, and embarked on ENTER- 
PRISE offer maximum versatility enabling ENTER- 
PRISE and her Air Wing to accomplish a variety of 
tasks. Task Force ONE is scheduled to arrive in 
Norfolk, Va., on October 5, 1964, concluding the two 
month operational evaluation and good will circum- 
navigation of the world. 



FROSTBITE 



By Bradford Washburn 
Director, Museum of Science, Boston, Mass. 
(This article is reproduced from The Polar Record, Vol II, No. 75 (September 1963) 
by kind permission of the author and the editor of that journal. It originally appeared 
in the American Alpine Journal, 13:1-26, June 1962, and was reproduced, in slightly 
different form, in the New England Journal of Medicine 266:974-989, May 10, 1962. 
This article is a slightly shorter version containing subject matter from both originals. 
Appreciation is extended to Mr. Washburn for permission to publish this article, in the 
Medical News Letter. Because of its length, three installments will be required. — Editor) 



INTRODUCTION 

Very significant progress has been made during the 
last decade towards an understanding of the nature of 
frostbite. Furthermore, recommended treatment today 
is so drastically different from the generally accepted 
practice of only a few years ago that it seems most im- 
portant for modern methods to be understood and ap- 
plied as widely and rapidly as possible. Although this 
article has been written primarily for those interested in 
climbing and exploring in high mountains, it is hoped 
that the data in it may prove as useful to the lowland 
traveller or outdoor labourer as to the mountaineer. 

Frostbite can usually be prevented by experienced 
leadership, good physical condition and adequate food 
and equipment, intelligently used. But, occasionally, 
in extreme circumstances such as those surrounding an 
accident, an emergency bivouac or an unexpected 
storm, it may prove very difficult to avoid. For example, 
a deep cut in the hand of a member of the well-equipped 
and experienced 1932 Minya Konka expedition ulti- 
mately resulted in a very serious case of frostbitten feet. 

COLD CONTACT 

The type and duration of contact are the two most 
important factors in determining the extent of frostbite 
injury. Touching cold wood or fabrics is not nearly as 
dangerous as coming in direct contact with metal, par- 
ticularly if one's hands are wet or even damp. In the 
latter case, the skin usually is instantly cemented to the 
cold metal and is torn off when the hand is removed. 
This is the reason why silk or cotton gloves are often 
worn by surveyors, scientists and photographers who re- 
quire manual dexterity while handling extremely cold 
objects, not because these gloves have any insulative 



value of consequence, but because they prevent direct 

contact with the cold metal, which is such an excellent 
conductor. 

Air itself is a very poor thermal conductor. Cold air 
alone is not nearly as dangerous a freezing factor as a 
combination of wind and cold. The chilling effect of a 
temperature of — 7°C (20°F) combined with a 45-mile 
wind is identical to that of a — 40°C (-40°F) temper- 
ature coupled with a 2-mile breeze. Wind chill is 
slightly less at high altitudes, because of reduced air 
density (Falkowski and Hastings, 1958). 

Probably the most violent and rapid cases of freezing 
ever reported in medical literature were those related 
to the operations of the United States Army Air Force 
over Germany in World War II (Davis and others, 
1943). At one time during the winter of 1943 the 
frostbite injuries of the United States heavy-bomber 
crews were greater than all their other casualties com- 
bined. Most of these occurred in B-17 and B-24 air- 
craft flying at altitudes between 25000 and 35000 ft in 
temperatures of —32° to -43°C. When attacked, the 
only way that the "waist gunners" of these aircraft 
could operate their machine guns was to open the large 
"waist ports", through which the guns were fired, di- 
rectly into the frigid air, rushing by at about 200 miles 
per hour and swirling around the interior of the air- 
craft. 

Starting their work wearing heavy mittens and bulky 
sheepskin clothing, the gunners often threew away their 
gloves and even their jackets, working the guns bare- 
handed to assure better dexterity — which they felt nec- 
essary to save their lives. Terrible cases of frostbite 
resulted from these exposures, some of which lasted for 
only a minute or two, but which fulfilled perfectly all 
the requirements for acute contact: fear (even panic), 



U.S. NAVY MEDICAL NEWS LETTER 



exhaustion (the German attacks were often adroitly 
planned at the end of long flights on the return trip), 
hypoxia, and inadequate nourishment during many 
hours of tension, followed by tight gripping of a frigid 
solid object — often bare metal. Furthermore, the barn- 
like interior of the uninsulated fuselages of these aircraft 
made rewarming slow, if not virtually impossible. This 
situation probably will never again be duplicated, since 
all military aircraft are now heated and pressurized and 
their gunners no longer operate in the open. The frigid 
temperature of outer space can never affect air crews 
directly, for human beings cannot exist outside a pres- 
surized cabin at heights much above 40000 ft except 
briefly during free-fall parachute descents. At altitudes 
above 63000 ft human beings cannot exist at all unless 
in a pressurized suit or cabin — for above this height 
human blood boils at body temperature. 

Because many of the most serious cases of frostbite 
have originated at high altitudes — both on the ground 
and in the air — it has long been assumed by laymen 
that changes took place in the blood progressively at 
greater altitudes that made the patient more and more 
prone to frostbite. Exhaustive studies, however, indi- 
cate that reduction of atmospheric pressure has little, if 
any, effect on susceptibility to frostbite as a result of 
changes in the make-up of the blood. The greatly in- 
creased concentration of red cells resulting from an ex- 
tended stay at high altitude does not make the blood 
more viscous, nor does it slow down capillary circulation 
or have any other presently known bearing on cold 
injury. 

There is one part of the body, however, where the 
lowering of pressure has an immediate and significant 
effect, one that grows increasingly serious above about 
10000 ft; this is the brain. Hypoxia * brings about an 
insidious reduction in reasoning powers, with a tendency 
to make one lazy, careless, indecisive and lacking in the 
endurance, insight and judgement normally encountered 
at sea level; this is all the more dangerous because each 
member of the party always sees these manifestations 
clearly in others but is solidly convinced that he alone 
is not being affected. 

Life itself at high altitude involves many basic 
changes, all of which contribute to increasing the danger 
of frostbite. Shelter is apt to become less and less com- 
fortable the higher one climbs. Cold steadily increases, 
as do the wind and the violence of storms. Loss of sleep, 
less adequate diet and finicky digestion, dehydration and 
greater nervous tension all contribute to a general level 
of bodily fatigue that is far above that experienced in 
the lowlands. One of the fundamental defences against 
frostbite is known to be a healthy body — yet a great 
number of factors inevitably related to high-altitude life 
are constantly whittling away at the well-being of even 
the toughest person. 

As the altitude increases and the oxygen supply is 



* Hypoxia is a disturbance of bodily function resulting from a de- 
ficiency of oxygen. This is sometimes confused with anoxia, a term 
that now means a total absence of oxygen. 



inadequate for normal breathing to satisfy the body's 
needs, the rate of exercise must be very carefully regu- 
lated. Huge quantities of body heat can be lost through 
the lungs by panting and over-exertion in extreme cold 
(Pugh, 1953). It is futile to pile layers of adequate 
clothing on the outside of one's body, only to have the 
major heat loss take place from within. Panting, too, in 
itself, can result in serious fatigue unless held in check, 
because even the muscles that operate the breathing 
have their own oxygen requirement. The harder they 
work, the more they use. 

One must remember that the body needs exactly the 
same amount of oxygen to do a given job at any altitude 
but the lungs must process more and more air to obtain 
this oxygen the higher one climbs. This purely mechan- 
ical process is always very carefully regulated by ex- 
perienced climbers. Excessive activity in extreme cold 
will not only exhaust the body but chill it to the core at 
the same time. 

Probably the two most important basic factors in the 
prevention of cold injury are the heat-producing capac- 
ity of the body and the effectiveness of measures to 
conserve heat, once it has been produced. It is also 
clear that the less heat the body is able to produce, the 
more carefully one must protect this vital resource. 

At higher altitudes the natural protective mechanism 
of shivering is impaired, and heat production during rest 
can therefore be seriously reduced in a crisis. If a 
climber is unable to exercise in extreme cold because of 
injury or exhaustion, it actually can become impossible 
for the body to retain an adequate level of heat produc- 
tion to meet the requirements of the situation. If this 
heat output falls below the danger point, the body then 
reduces the blood flow to its surface and extremities in 
a desperate effort to retain normal temperature at its 
core. In such a situation, no amount of insulation can 
prevent frostbite — and nothing but vigorous warming 
from an external heat source and, if possible, adminis- 
tration of oxygen can avert serious results. 

It is interesting that since oxygen has been employed 
extensively in High Himalayan mountaineering almost 
no frostbite has been encountered by the personnel ac- 
tually using it. Conversely, during the 1960-61 Makalu 
expedition, almost everyone who climbed above 24,500 
ft without oxygen suffered frostbite -in some degree — 
despite the fact that one of the prime objectives of this 
expedition was the study of acclimatization (Marmet 
and MacFarland, 1960). 

As the altitude increases, therefore, the danger of 
being frostbitten progressively increases. The margin 
of safety at the summit of Mount Everest is very slim 
indeed, except under extremely favourable conditions of 
both the weather and the physical well-being of the 
climbers. 

It is almost unnecessary to emphasize the great im- 
portance of an adequate diet for the production of body 
heat at all altitudes. Cold weather definitely increases 
caloric needs, and variations in diet can have equally 



U.S. NAVY MEDICAL NEWS LETTER 



definite effects on tolerance of cold (Mitchell and 
Edman, 1951). 

In cold-weather camping, particularly at high alti- 
tudes, cooking, dishwashing, thawing of food and melt- 
ing of water present a long, tedious project at best. Fre- 
quently, it is such a struggle to prepare a hot meal that 
one is tempted to get along with the minimum of food 
and water, particularly in bad weather. In addition, 
because of the miseries of backpacking, the higher one 
climbs, the more reduced, compressed, uninteresting and 
unappetizing food is apt to become, unless the party is 
patient and stubborn in its efforts to carry good food to 
all camps and unless the food itself is selected and pre- 
pared very carefully. Many high-altitude and stormy- 
camp meals would be close to repulsive if served in a 
warm dining room at sea-level — and this all goes on at 
a time when the need for plenty of good food is of vital 
importance. 

There is no better investment in the well-being, safety 
and efficiency of a party than appetizing food, plenty of 
it, well prepared. 

One should drink much more liquid than usual at 
higher altitudes to compensate for losses through the 
lungs as a result of breathing unusually large quantities 
of dry air. This means regularly drinking a good deal 
more liquid than seems necessary at reasonably frequent 
intervals in camp and on the trail; just what seems 
enough is not sufficient. 

At low altitudes, diet in cold weather should tend 
heavily towards fats, which can be tolerated in amazing 
quantities by men doing heavy exercise in extreme cold. 
Carbohydrates rate next in importance and proteins 
follow a poor third. Few common foods represent pure 
examples of any of these three types. For instance, 
stews and hashes are usually a mixture of all three, 
many cereals combine both carbohydrates and proteins, 
and all meats are a combination of both protein and fat. 
The following list may be of help in indicating the 
basic composition of some of the common foods. The 
first letter indicates the dominant component. Small 
letters indicate a small fraction of the overall com- 
position. Hyphens indicate a trace or absence. 
Bacon Fp- Flour (White ) Cp- 

Beans (dried) CPf Fruits Cp- 

Beef (chipped) Pf- Ham FP- 

Biscuits (pilot) Cp- Honey C~ 

Bread (white) Cp- James & Jellies C- 

Butter F— Macaroni Cp- 

Dates Cp- Meats (average 

Candies (hard) C- fat content) PF- 

Cereals (oatmeal) Cp- Milk (whole) PFc 

Cheese FP Milk (non-fat dried) Pc- 

Chicken Pf- Nuts FPC 

Chocolate FC- Most pemmicans FP- 

Eggs (whole) PF- Potatoes (dried) C~ 

Fish PF- Soups (dried thick) C- 

Fish (packed in oil) FP- Sugar (granulated) C- 

As altitude increases above 10000 ft, carbohydrates 



should be favoured, with fats and proteins following in 
that order. Sweets of all sorts are as appetizing in cold 
weather at high altitude as fats are in the cold-weather 
trail diet in the lowlands. 

Although fats are a great heat producer at any alti- 
tude, many climbers seem to find them difficult to digest 
above about 14000 ft. They should not be heavily re- 
lied upon above that height unless it is known from 
previous experience that all members of the party like 
them and can tolerate them. The failure of the mag- 
nificent Parker-Browne assault on Mount McKinley in 
1912 was the direct result of its total dependence on a 
very fatty pemmican diet. This had proved a great 
success below 14000 ft but turned out to be totally re- 
pulsive to the entire party at its 16400 ft camp. 

Losses of body heat can be tremendous in cold 
weather at high altitude. Huge caloric input is needed 
to offset them, and it is vitally important not to waste 
effort backpacking any food to high camps that cannot 
be easily and pleasantly converted into useful energy. 
It should not be forgotten that a pressure cooker can be 
a great asset in making rapidly available at high alti- 
tudes all sorts of excellent foods that until recent years 
were considered uncookable above 10000 ft. Frozen 
fresh fruits, vegetables and meats, where practical to 
use in the field, can also produce miracles in both the 
morale and physical well-being of a party operating 
under rough conditions of weather and altitude. 

Changes in the circumstances surrounding frostbite 
injury can result in substantial difference in the amount 
of damage done under nearly identical climatic condi- 
tions. Frostbite is rarely experienced by a healthy per- 
son standing still and adequately clothed (like a sentry) . 
It almost always seems to be related to other factors 
such as fatigue, a sudden storm or an accident — or com- 
binations of them. In civilization, intoxication is a well 
known and frequent forerunner of frostbite. 

Injury to any part of the body, combined with a 
certain amount of shock and resultant fear and panic, 
can introduce serious frostbite into an accident situation 
in which the climatic conditions alone would not have 
caused any trouble to seasoned, uninjured persons. If 
the members of a party are already exhausted at the 
time that an accident occurs, both shock and frostbite 
can be much more serious. It is also exceedingly diffi- 
cult to rewarm and maintain the general body warmth 
of a hypoxic injured patient — and advanced general 
body cooling can be a tremendous factor in the onset of 
both shock and frostbite. A striking example of this 
related in a recent letter regarding the 1961 crisis on 
Makalu, a 27790 ft. Himalayan peak immediately ad- 
jacent to Mount Everest: "Frostbite doesn't occur very 
often unless there is overall heat deficit in addition to 
cooling of the extremity. Take Peter Mulgrew's case. 
He had a pulmonary thrombosis at 27450 ft. During 
the ten days it took to evacuate him to lower altitudes 
and then to Katmandu by helicopter, he was completely 
inactive and had a minimal heat production — probably 



U.S. NAVY MEDICAL NEWS LETTER 



basal or even less. On top of this he had some degree 
of shock much of the time, which impaired his periph- 
eral circulation considerably. Therefore, although he 
had warm socks, down booties and a good double sleep- 
ing bag, he was severely frostbitten and lost both legs 
below the knee, as well as parts of some fingers. This 
was the result of low heat production, not faulty cloth- 
ing" (Nevison, 1961). 

Because impaired local circulation is the primary 
cause of frostbite, an effort should be made at any alti- 
tude to avoid anything that is known to have even a 
mildly adverse effect on norma! peripheral circulation, 
in particular tobacco and alcohol. Smoking results in 
varying degrees of spasm in the blood vessels through- 
out the entire body, thus reducing normal peripheral 
circulation and the flow of oxygen and nourishment to 
tbe tissues, at a time when both are badly needed. On 
the other hand, alcohol results in vascular dilatation and 
an increased flow of blood at the surface of the body. 
This blood is unduly chilled and, as it returns to the 
heart and lungs, may lower the temperature of the 
whole body significantly. Although the use of alcohol 
(even in moderation) is not recommended at any time 
on the trail — particularly in an emergency — smoking 
does not seem to have any direct bearing on frostbite, if 
one does not smoke actually at the time when the danger 
of frostbite exists or while it is being treated. Habitual 
heavy smokers do not appear to be more subject to 
frostbite than others. 

It is well to remember that deep, loose snow can 
contribute to frozen feet in a most unexpected manner. 
While on equipment tests near the summit of Mount 
McKinley some years ago, members of our party found 
it extremely difficult to keep their feet warm, although 
it was clear and sunny and the air temperature was 
warm, —17° or — 15°C (2° or 3°F), with, very little 
wind. The next day, one of the party dropped a ther- 
mometer in the loose snow at our high camp and took a 
minute or more to relocate it. The air temperature was 
-18°C. The thermometer registered -25°C (-14°F) 
a foot betow the surface. The temperature beneath 
deep snow is frequently very different from that on the 
surface. Feet should be dressed for the temperature 
where they are — not where the head is. While one is 
resting on the trail or at lunch, it is usually wise to get 
one's feet up into the sun in a sheltered spot. Often, 
however, in windy weather the temperature in the 
shetter below the surface of the snow is much warmer 
than on top, even in the sunlight. By using his head 
constantly in cold weather the climber can protect his 
body from a very large amount of unnecessary stress 
and strain. 

Previous experience with frostbite frequently results 
in a longterm reduction in anyone's tolerance to cold in 
the injured part. Conversely, whether there is or is not 
such a thing as bona fide physiological adaptation to 
cold has been an extremely controversial matter for a 
long time. There is not the slightest doubt that Eskimos, 
Tibetans and other natives in cold, rugged climates 



"feel" cold much less than "outsiders"; Bald porters, for 
example, can walk barefoot for hours through the 
Himalayan snow, carrying heavy loads at 13000 to 
16000 ft, without visible injury or discomfort. Their 
hardy physical well-being and tough, weather-beaten 
faces, hands and feet certainly seem to resist cold more 
than those who do not live as they do. They obviously 
tolerate cold better than those who live in temperate and 
tropical climates (Yoshimura and others, 1960). 

However, many medical experts have long insisted 
that this alleged "resistance" is really no more than the 
result of lengthy experience in Arctic survival and day- 
to-day living, under conditions far worse than those 
encountered outside of their homeland. It is further 
agreed — and warned — that Eskimos, even though they 
do not feel cold as fast or as much as outsiders, will 
freeze just as fast and just as badly as others, given the 
same actual contact situation. 

Recently, a more and more serious attack is being 
made on this interesting subject by a number of con£ 
petent investigators who believe that under certain cir- 
cumstances there may really be such a thing as cold 
adaptation. However, even if this research ultimately 
meets with acknowledged success, it may prove of little 
but academic value to all but Eskimos and Tibetan 
climbers. The basic reasons why most seasoned out- 
doorsmen are not frostbitten are that they tend to be in 
good physical condition and that they know how to act 
and dress to prevent it. 

Frostbite can result in serious and crippling injury, 
and even mild exposure should be avoided with great 
care. (To be continued.) 

* * "It {this article) has considerable direct reference to specific 
problems of high altitude as well as extreme cold. However, 
since the currently accepted treatment of frostbite and the ways 
to avoid it are identical for all places and altitudes, it is believed 
that the facts and advice given should be of general value and in- 
terest to both doctors and laymen alike. The author has been to 
Alaska 23 times, both summer and winter, and he has been an 
expert consultant on cold-climate equipment to both the United 
States Air Force and the Army. 

It is eivdent that he partcices what he preaches, for only 1 slight 
case of frostbite has occurred among all the personnel involved 
in his total of 15 major forays into the high mountains of Alaska. 
Three of these have been ascents of Mount McKinley {20320 ft) 
and have been carried out under full winter conditions. Well 
over 100 different people have participated in this field work, 
much of which has been directed toward the preparation of a 
new and detailed map of the Mount McKinley region, published 
in April, 1961." 

The above comment ** and the following editorial ap- 
peared in the same issue of the New England Journal of 
Medicine as Mr. Washburn's article: 

"TO WALK ON FROZEN TOES" 

Ice-age man was obviously aware of the serious na- 
ture of injuries produced by cold, and satisfactory 
methods for their prevention was a prerequisite to his, 
as well as to contemporary man's survival. It is 
interesting that in primitive people living in northern 
climates serious cold injury seldom develops under 
ordinary conditions. 



U.S. NAVY MEDICAL NEWS LETTER 



Frostbite was regarded as negligence and was an 
offense punishable by death in the German and Russian 
armies during World War II. Relatively few cases of 
frostbite occurred among these soldiers, in marked con- 
trast to the very high incidence among American troops 
exposed under identical conditions, insufficient aware- 
ness of the basic principles for the prevention of cold 
injury undoubtedly having been a major factor in caus- 
ing this difference. 

Modern man incurs a greater risk of frostbite than 
primitive man because of such necessities of life as 
loading cameras, handling gasoline and operating deli- 
cate instruments under conditions of extreme cold and 
frequently high altitudes. The combination of increased 
susceptibility and decreased awareness of the hazards 
and methods for prevention of cold injury is making 
frostbite an increasingly common disease among people 
accustomed to high standards of living. 

Until recent years there has been no controlled ex- 
perimental scientific basis for the treatment of frostbite. 
Basic conservatism and the belief founded in antiquity 
that marked differences in temperature were to be 
avoided led to the general acceptance of gradual re- 
warming as being almost axiomatic in the treatment of 
frostbite. Such beliefs are so deeply ingrained in the 
minds of professional persons and laymen alike that they 
are difficult to eradicate. An informal cafeteria poll of 
physicians of all specialties shows that there is still an 
approximately 3 : 1 preference for gradual versus rapid 



rewarming of frozen extremities. When these physicians 
were asked the experimental basis for their preference, 
the majority reflected and said they did not know. 

The armed forces have expended considerable sums 
of money for study of the most effective means for 
thawing frozen parts, and the experimental evidence and 
clinical results of rapid rewarming in decreasing the 
amount of permanent tissue loss of frozen extremities 
are now clear. The results of these studies should be 
widely disseminated. 

Mr. Washburn has discussed the subject of frostbite 
in a most interesting and thorough fashion. His article 
which appears elsewhere in this issue of the Journal, is 
obviously the product of great personal experience as 
well as intensive study of the bitterly learned lessons 
and personal tragedies of many others. 

Frostbite is one of the emergency conditions, such as 
drowning, acute respiratory obstruction, precipitous 
labor and hemorrhage, that any physician may be called 
upon to treat at any time. Treatment must frequently 
be undertaken without recourse to the library or con- 
sultation with experts. It is strongly recommended that 
every physician and medical student familiarize himself 
with the principles discussed in Mr. Washburn's im- 
portant paper, mindful of Edwin A. Robinson's poem 
"New England.": 

Here where the wind is always north-north-east 
A nd children learn to walk on frozen toes. 



If carried out in suitable conditions, physical activity is 
unlikely to aggravate the condition of the patient with 
heart disease, and indeed will probably be of benefit to 
him. If he is in regular employment, however, he may 
have to cut down such leisure activities as gardening 
and odd jobs about the house. — WHO Chronicle 18(6) : 
218, July 1964. 

In some parts of India, it has been estimated, one 
child in 800 under 5 years of age dies of measles or its 
complications, and the situation is thought to be much 
worse in parts of Africa. Even in the developed coun- 
tries measles is now suspected of being considerably 
more serious than had generally been believed. Safe 
and effective prophylactic measures against this disease, 
which practically every child contracts, are clearly 
needed. Various types of measles vaccine are now be- 
ing studied in a number of countries. — WHO Chronicle, 
18(3): 81, March 1964. 

The available figures suggest a world-wide decline in 
maternal mortality between 1950 and 1960. The great- 
est improvement was observed in the figures for death 
from toxaemias of pregnancy and the puerperium and 
from complications of pregnancy, childbirth, and the 
puerperium, which together accounted for more than 
50% of maternal deaths. Abortion with or without 



sepsis, which accounted for about 10% of such deaths, 
showed an increase in some countries. — WHO Chron- 
icle, 18(3): 100, March 1964. 

Prompt Identification of Food Poison. Use of gel diffu- 
sion to identify the specific staphylococcal toxin respon- 
sible for the majority of food poisoning outbreaks in the 
United States was announced in November 1963 by the 
U. S. Food and Drug Administration, simultaneously 
with similar reports by the Public Health Service. The 
gel double diffusion test, the goal of 15 years' research, 
employs a serologic method. Minute quantities of En- 
terotoxin A can be detected through the use of the 
antibody produced in rabbits by injection of the entero- 
toxin. 

In the past, it has been necessary to isolate the bac- 
teria from suspected foods and demonstrate toxicity by 
feeding monkeys or injecting cats. These tests were 
time consuming and not always reliable because animals 
vary in susceptibility to toxins. 

In the FDA test, the suspected food sample is placed 
in an electric blender and thoroughly homogenized. A 
special glass column containing certain chemicals is used 
to separate the toxin from the food substances. The 
toxin is removed from the chemicals and concentrated. 
—Public Health Reports 79(2): 179, February 1964. 



U.S. NAVY MEDICAL NEWS LETTER 



UROLOGIC DIAGNOSIS 



B. G. Clarke MD, Associate Professor of Urology, Tufts University School of Medicine 
and }. Hartwell Harrison MD, Clinical Professor of Genito-Urinary Surgery, Harvard 
Medical School. Reprinted by permission of the authors from "Diseases' of the Urinary 
and Genital Organs" (A Review and Bibliography) — pps 8-12, Boston, Mass., I960.* 



The Abdominal X-Ray 

The plain film of the abdomen or "K. U. B." (kidney- 
ureter-bladder) x-ray is the basic study in all radiog- 
raphy of the urinary tract. It is often diagnostic. It is 
an essential preliminary study before contrast radiog- 
raphy. The plain film is studied for opacities due to 
calculi or foreign bodies; for soft tissue masses; for 
abnormal organ contours; for abnormal gas patterns in 
the bowel, and for skeletal abnormalities such as frac- 
tures, osteoporoses and metastatic lesions. 

In plain abdominal x-rays of good quality one usually 
sees not only skeletal shadows, bowel patterns, and 
abnormal calcifications but also the outlines of the kid- 
neys, liver, spleen, psoas muscles, lateral abdominal 
wall and peritoneum as well as visceral tumors if they 
exist. In the upright or lateral positions it is also 
possible to demonstrate, in cases of ruptured viscus, in- 
traperitoneal free air or in cases of intestinal obstruction, 
dilated bowel loops with fluid levels. 



Value of Plain Film in Renal Mass Lesions (Tumors and Cysts). 
Ettinger, A.; and Elldn. M.; Radiol 62: 372-382, March 1954. 



Intravenous Pyelograms 

Intravenous pyelograms, or excretory urograms, as 
they are also called, are made by injecting a radio-paque 
organic iodide solution intravenously. This is selectively 
excreted by the kidney and concentrated in the urine 
within a tew minutes by a combination of glomerular 
filtration and tubular excretory mechanisms. The renal 
cortex is rendered visible by faint opacification, while 
the calyces, pelvis, ureters and bladder become visible as 
they fill with iodide-containing urine. This constitutes a 
physiologic and visual study of the upper, mid and 
lower urinary tracts. 

X-rays made at timed intervals permit estimation of 
renal excretory function, study of the outlines of the 
renal cortex, and roentgen visualization of the ureters 
and bladder. Comparison of films usually demonstrates 
the serial phases of ureteral peristalsis. As the bladder 
fills with radiopaque urine its pathology may be seen 
although exact diagnosis of bladder lesions requires 
cystoscopy. A film made after voiding shows whether 
or not there is persistent residual urine. 

Intravenous pyelograms or excretory urograms are 
useful in nearly all cases of suspected renal pathology. 



Contrast media are not usually excreted in diagnostic 
concentration if blood urea nitrogen exceeds 50 mgm 
per cent. Intravenous pyelograms should not be made 
if a patient is known to be sensitive to iodides, nor in 
individuals with a history of asthma. Severe and occa- 
sionally fatal anaphylactoid reactions can occur. The 
death rate from such complications is about 1 in every 
120,000 intravenous pyelograms. Excretory urography 
should never be performed indiscriminately. Prelim- 
inary intradermal or ophthalmic tests for sensitivity do 
not assure that reactions will not occur. A test dose of 
1 cc is given intravenously and if no reaction occurs 
19-20 cc is slowly injected over a period of 5 to 10 
minutes. Equipment for resuscitation, instantly avail- 
able, should include intravenous injections of adrenalin 
and antihistamine, an infusion set with plasma expander 
in the event of peripheral vascular collapse, laryngo- 
scope, endotracheal tube and a tracheostomy set to be 
used if there is evidence of respiratory obstruction due 
to laryngeal angioneurotic edema. 



Comparative Studies of Urographic Media. Culp, D. A.; Van Epps, 
E. F.; and Edwards, C. N.: J Urol 78: 493-495, October 1957. 

Evaluation of Contrast Media for Excretory Urography. Utz, D. C; 
and Thompson, G. J.: Proc Staff Meet Mayo Clin 33: 75-80, Feb- 
ruary 19, 1958. 

Reactions Associated with Intravenous Urography: Historical and 
Statistical Review. Pendergrass, H, P.; Tondreau, R. L.; Pender- 
grass, E. P.; Ritchie, D. J.; and Others. Radiology 71: 1, 1958. 

The Limitations of the Intravenous Pyelogram as a Test of Renal 
Function. Hoffman. W. W.; and Grayhack, J, T, Surg, Gyne, & 
Obst 110: 503-509, April 1960. 



* For further information regarding the authors and their publication, 
see the Medical News Letter 44(3): 13, August 7, 1964. 



Cystoscopy and Retrograde Pyelography 

Cytoscopes and urethroscopes are delicate telescopic 
instruments introduced perurethrally which provide a 
magnified view of the interior of the bladder and 
urethra. The essential components are a delicate metal 
sheath which is lighted at its tip, a magnifying lens sys- 
tem, and an irrigating system used to distend the organs 
with clear, sterile fluid. 

Many variations of such equipment are available. It 
is possible, using these instruments, to perform accurate 
diagnostic inspection of all parts of the lower urinary 
tract, to make biopsies, to intubate (catheterize) the 
ureters, to remove or electrocoagulate bladder cancers, 
to resect prostatic hypertrophy, to excise prostatic bars 
and congenital prostatic valves, to incise strictures of 
the ureteral orifices, to extract stones from the ureters 
and to crush and evacuate stones from the bladder. 



U.S. NAVY MEDICAL NEWS LETTER 



With the aid of the cystoscope, delicate catheters may 
be inserted into the ureters or renal pelvis. These may 
be used to collect urine for cultures, for microscopic and 
chemical analysis and for separate functional studies. 
The retrograde injection of nontoxic and nonirritant 
organic iodide solutions permits visualization of the 
renal collecting system or ureters. Retrograde pyelog- 
raphy is used when intravenous studies are contraindi- 
cated or when they fail to yield x-rays of diagnostic 
quality. 



Clinical Cystoscopy. McCrea, L. E., Phila., F. A. Davis, 1940 (2 
vols) 



Cystograms, Cystourethrograms 

A cyostogram is a contrast study of the bladder made 
with intravenously injected media or by retrograde in- 
jection of air or iodide solution. The cystourethrogram 
is an extension of this technic. The urethra (as well as 
the bladder) is delineated by making an x-ray during 
injection of a column of radiopaque, nontoxic contrast 
substance and also, again, while the patient voids. 

Radiologic Diagnosis of the Lower Urinary Tract. Beard, D. E.; 
Goodyear, W. E.; and Weens, H. W.: Springfield, 111., Charles C. 
Thomas, Publishers, 1952. 



Retroperitoneal Pneumograms 

When adrenal or retroperitoneal tumors are suspected 
and cannot be demonstrated by plain radiography, they 
may often be outlined by gas contrast. This is ac- 
complished by presacral injection of carbon dioxide (the 
safest medium if it should enter the circulation) into 
the retroperitoneal areolar tissue. Because of the danger 
of gas embolisms which can be fatal, the examination 
must be undertaken with circumspection. 



Presacral Retroperitoneal Pneumography Utilizing Carbon Dioxide: 
Further Experiences and Improved Technique. Landes, R. R.; and 
Ransom, C. L.: J Urol 82: 670-673, December 19S9. 



Renal Angiography 

Angiograms of the renal vessels can be made by 
translumbar intraaortic needle injection of organic 
iodide solution or by introducing a catheter, for the 
same purpose, through the femoral vessels. They are 
particularly indicated in the study of renal vasculature 
in cases of hypertension of suspected renal origin. They 
are also indicated, occasionally, in the study of other 
types of renal pathology. 

Renal angiography has the disadvantage that rarely 
but occasionally the concentration of the contrast 
medium is sufficiently great in the kidney vessels to 
cause fatal tubular necrosis; in the mesenteric vessels to 
cause fatal mesenteric thrombosis; and in the vertebral 
circulation to cause toxic myelitis and permanent 
paraplegia. 

Aortography. Its Application in Urological and Some Other Condi- 
tions. Stirling, W. R. : Edinburgh and London, E. & P. Livingstone, 
Ltd. 1957, pp 292. 



Complications of Aortography, Crawford, E. S.; Beall, A. C.j Moyer, 
J. H.; and DeBakey, M.: Surg, Gyne, and Obst 104: 129-141, 
February 1957. 

PATHOGENESIS AND TREATMENT OF 
URINARY INFECTION 

Pathogenesis 

Bacteria may enter the urinary tract via the blood- 
stream (hematogenous infection), the lymphatics, or 
the urethra (ascending infection). Renal tissue dam- 
aged by previous infections, by trauma, or by chronic 
urinary obstruction is peculiarly susceptible to infection. 
Foreign bodies (stones, catheters) and urinary retention 
due to neurogenic or mechanical obstruction likewise 
favor the development of infection and hinder its dis- 
appearance. On account of these factors, any urinary - 
infection which persists or recurs demands not only 
accurate bacteriologic study of the urine but pyelograph- 
ic or often cystourethroscopic study to identify mechan- 
ical or obstructive abnormalities the correction of which 
is essential before antibacterial agents can be effective. 
Unimpeded ureteral peristalsis and normal reflex empty- 
ing of the urinary bladder must be restored if treatment 
of infection is to succeed. 



Chronic Pyelonephritis. Hayman, J. M. Jr.: Bull Tufts-New England 

Med Ctr 1: 65-71, April-June 1955. 
Clinical Features of the Contracted Kidney Due to Pyelonephritis. 

Longcope, W. T., and Winkenwerder, W. N. : Bull Johns Hopkins 

Hos 53: 255-287, November 1933. 
Bacteriuria and Diagnosis of Infections of Urinary Tract: with 

Observations on Use of Methionine as Urinary Antiseptic. Kass, 

E. H. Arch Int Med 100: 709-714, November 1957. 
Pyelonephritis. Kleeman, C. R.; Hewitt, W. L.; and Guze, L. B. : 

Medicine 39: 3-116, February 1960. 
Chronic Bilateral Pyelonephritis: its Origin and Its Association with 

Hypertension, Longcope, W. T. : Ann Int Med 11: 149-163, July 

1937. 
Role of Ureter in Pathogenesis of Ascending Pyelonephritis. Talbot, 

H. S.: JAMA 168: 1593-1603, November 1958. 



Types of Infection 

Cystitis. In certain situations ascending urinary in- 
fections will usually remain localized in the urethra and 
bladder without involving the kidneys. Notable in- 
stances are cystitis associated with well-functioning 
suprapubic or urethral catheter drainage of the bladder; 
with prostatic infections in the male; and acute un- 
complicated bacterial cystitis in female patients. The 
symptoms of acute cystitis and prostatitis are similar: 
frequency; dysuria; urgency; not infrequently hematuria; 
and in male patients, slowed voiding as the result of 
prostatic edema. Prostatitis often causes perineal pain, 
while inflammation or distension of the seminal vesicles 
may cause abdominal pain. 

Pyelonephritis. The pathologic process is one of dif- 
fuse renal inflammation, not infrequently of variable 
intensity or focal character. Pure "pyelitis" probably 
does not occur. In fulminant infections especially in 
diabetes, renal papillary necrosis occurs. The pyelo- 
nephritic process becomes more chronic, renal secretory 



U.S. NAVY MEDICAL NEWS LETTER 



tissue is gradually replaced by scar; function diminishes, 
the kidney contracts; and hypertension not infrequently 
supervenes. 

Although pyelonephritis may be of insidious onset 
and reach chronic form without causing any symptoms, 
in its typical acute form it causes renal pain and tender- 
ness and fever, and leukocytosis. These symptoms are 
commonly associated with urinary frequency during the 
acute phase of the disease. 

Renal Carbuncle; Perinephric Abscess. These forms 
of kidney infection, while related to pyelonephritis 
pathologically are marked by development of suppura- 
tive foci in the glomerular zone of the kidney. As an ab- 
scess localizes it may remain intrarenal (renal car- 
buncle) or dissect outward through the renal capsule 
and into adjacent tissue planes as a perinephric abscess. 
Hematogenous etiology is common. The symptoms of 
this group of infections usually appear slowly, several 
weeks after the primary pyogenic infection. The onset 
is insidious as fever of unknown origin, a vague pain in 
the back, malaise and muscle spasm causing functional 
scoliosis gradually appear. Spasm of the iliopsoas 
muscle causes hip flexion. There is always a leucocytosis. 
Although the urine at first may show no leucocytes the 
stained sediment contains Gram positive cocci and per- 
haps also Gram negative bacilli. Ileus causing abdom- 
inal distention is a prominent physical finding. Deep 
tenderness in the flank is present, similar to that seen 
with acute pyelonephritis but with a more sustained 
discomfort persisting after palpation. A plain film of 
the abdomen shows enlargement of the renal shadow 
with obscuration of the perinephric markings; loss of 
the iliopsoas muscle shadow is common and the lumbar 
scoliosis with concavity towards the involved side is 
almost invariably striking. Urography may show dimin- 
ished excretion and distortion of calices. 

Treatment. The treatment of cortical abscess and/ or 
perinephric abscess, once the diagnosis has been made, 
consists of incision and drainage. When a perinephric 
abscess is drained careful search over the surface of 
the kidney for evidence of an area of softening in the 
cortex must be made to assure that a cortical abscess 
is not also present. 



Ureteritis Cystica: Treatment with Sulfadiazine, Penicillin and Aureo- 
mycin. Report of a Case. Clarke, B. G.: J Urol 68: 815-818, 
November 1952. 



Renal Carbuncle. Report of a Response to Modern Treatment. Colby, 

F. G,; Baker, M. P.; and St. Goar, W. T.: New England J Med 

256: 1147-1148, June 13, 1957. 
Perinephric Abscess in Infants and Children. A Study of Twenty-six 

Patients Surgically Treated. Swan, H.: Amer J Surg N. S. 61: 3-10, 

July 1943. 



Pyeloureteritis and Cystitis Cystica 

These are variant forms of urinary infection in which 
subepithelial cysts appear, representing a proliferative 
reaction of the transitional cell epithelium of urinary 
tract to chronic inflammation. Treatment is that of the 
underlying bacterial infection, cure of which often 
causes the lesions to regress. 



Principles of Treatment 

In the diagnosis of urinary infections cultural testing 
of organisms for sensitivity to drugs should be carried 
out when possible. As a practical matter, urine is col- 
lected for culture at the patient's first visit. Treatment 
is immediately prescribed, in acute infections, on the 
basis of stained smears of urinary sediment or upon 
empirical considerations. If improvement is not evident 
within 12 to 36 hours, by the end of which cultures 
should have grown out, it may be assumed that use of 
another drug is in order. This may then be selected on 
the basis of drug-sensitivity tests. 

In vitro testing of microbial drug sensitivity by disc 
or tube dilution methods is about 80 per cent reliable, 
and a real help in planning therapy. The final test of 
effectiveness of a drug is in cure. When a medication 
to which micro-organisms are sensitive in vitro fails to 
produce cure one of two things may have happened: 
( 1 ) The organism is, notwithstanding laboratory re- 
ports, not sensitive to the drug, or (2) the patient has a 
structural change in the urinary tract such as hydro- 
nephrosis, prostatic obstruction, a foreign body or a 
stone which is preventing cure. The patient with re- 
fractory urinary infection therefore immediately be- 
comes a candidate for excretory pyelograms, perhaps 
for cystoscopy, and for very careful clinical and bac- 
teriologic re-evaluation. 

Acute, uncomplicated urinary infections originating 
for the first time in a structurally normal urinary tract 
are usually due to a single micro-organism. E. coli is 
the commonest invader, and enterococci and Aerobacter 
aerogenes also are rather frequent. Uncomplicated 
acute infections are often self-limited; and almost always 
respond promptly to treatment. 

Chronic urinary infections are more often due to 
mixed flora. Atkaligenes fecalis, Pseudomonas aerugi- 
nosa, staphylococci, streptococci, and other forms are 
found as well as the coli-aerogenes-enterococcus group. 
Chronic infections are commonly associated with radi- 
ologically demonstrable structural changes in the urinary 
tract: congenital anomalies, hydronephroses, calculi, 
prostatic obstructions, urinary fistulas, neurogenic dis- 
orders of the bladder, as well as with structural damage 
of the kidney due to infection itself and resulting 
fibrosis. When such infections progress to chronic 
pyelonephritis they are difficult to cure and may result 
in uncontrollable renal failure and hypertension. 

While empirical treatment of an apparently uncom- 
plicated and mild urinary infection is permissible the 
first time the patient is seen, treatment-failure always 
demands explanation. Intravenous pyelography should 
be performed and may be expected to disclose structural 
changes if any are present to account for treatment 
failure. The examination is contraindicated in patients 



U.S. NAVY MEDICAL NEWS LETTER 



with asthma or with a history of iodide sensitivity. Even 
in otherwise normal subjects reactions to the contrast 
medium occasionally occur. Since the incidence of 
fatal reactions is in the vicinity of 1 in 120,000 exam- 
inations the procedure should not be undertaken unless 
equipment is at hand for resuscitation. Fatalities usual- 
ly result from respiratory failure due to bronchiolar 
spasm. Accurate bacteriologic study of the urine is 
essential to the management of a urinary infection not 
responding to initial empirical treatment or recurring 
after apparently successful initial treatment. 

The management of acute, servere urinary infections 
is an urgent matter. The majority of these patients re- 
quire hospitalization if facilities are available. Imme- 
diate studies must include not only careful history- 
taking, physical examination and urinalysis, but imme- 
diate attempt to classify the responsible micro-organism 
by staining of the urinary sediment. Before therapy is 
begun, urine cultures are planted. If facilities are avail- 
able cultures should be made by quantitative technics 
and in-vitro drug sensitivity tests should be performed. 
It is, however, unnecessary and undesirable to wait for 
the results of cultures before beginning treatment. 



If an acute infection does not show signs of ameliora- 
tion with 24 to 48 hours it is likely that the organism 
is insensitive to the drug chosen or that un-drained sup- 
purative infection (pyonephrosis due to urinary obstruc- 
tion, or perinephric or intra-renal abscess for example) 
is present. Investigations such as pyelography may be 
indicated. Prompt reassessment of the therapeutic plan 
in terms of results of bacteriologic cultures is required. 
It should be noted that in-vitro sensitivity tests although 
extremely useful do not always correlate exactly with 
the way micro-organisms behave in clinical infections. 
If a drug indicated by such tests fails it may be neces- 
sary to employ other agents, or combinations of agents. 
The advantages of particular agents in any situation 
must be balanced against their potential toxicity. Drug 
combinations of possibly synergistic action have a defi- 
nite place in treatment of urinary infections. 
(Three pertinent tables on the treatment of GU infec- 
tions, including drugs of choice and bibliography on 
therapy will appear in a later issue of the Medical 
New Letter) 



FROM THE NOTE BOOK 



SURGEON GENERAL PRAISES 
CHIEF ATZERT 

RADM E. C. Kenney MC USN, Surgeon General, 
gave the following letter to Joseph J. Atzert HMCM 
USN on 31 August 1964: 

"On the occasion of your transfer, I wish to express 
appreciation for your outstanding performance of duty 
while assigned to the Hospital Corps Division, Bureau 
of Medicine and Surgery, during the period January 
1962 to August 1964. 

"Throughout this time you have performed all assign- 
ments in an exemplary manner. As the leading chief 
petty officer of the Distribution Section, you have con- 
sistently demonstrated the maturity, judgment, and sense 
of responsibility so necessary in filling that demanding 
position. Your insight into the personnel requirements 
of the Medical Department, coupled with the nicest 
sense of fairness and consideration for your fellow 
Hospital Corpsmen, has gained you many friends, both 
professional and personal, and has greatly enhanced 
the reputation of the Hospital Corps. Your military 
bearing and leadership have always been above re- 
proach, and have reflected credit upon yourself, this 
Bureau, and the Naval Service. 

"I extend my personal congratulations for a job 
"WELL DONE", and wish you continuing success in 
your Navy career." 



Medical News Letter Erratum Notice 

The information contained on Page 20 of Volume 44, 
Number 4, 21 August 1964 issue was partially in error. 

The heading "U. S. Naval Hospital, Navy Prosthetic 
Research Laboratory, Oakland 14, Calif." should be 
"U. S. Naval Hospital, Clinical Investigation Center, 
Oakland, Calif. 94614." 

DISCONTINUANCE OF CORRESPONDENCE 

COURSE SUBMARINE MEDICINE PRACTICE, 

NAVPERS 10707-A 

Officer Correspondence Course Submarine Medicine 
Practice, NavPers 10707-A, is discontinued pending 
revision. All personnel who are currently enrolled in 
this course will be permitted to complete the course. 

SENIOR FOREIGN MILITARY MEDICAL 

OFFICERS CONVENE FOR SEVENTH 
ANNUAL TRAINING PROGRAM AT U. S. 

NAVAL MEDICAL SCHOOL, UNDER 

SPONSORSHIP OF THE CHIEF OF NAVAL 

OPERATIONS 

Welcome Aboard ceremonies were conducted by the 
Commanding Officer of the U. S. Naval Medical School 
on 27 August 1964 for the Senior Foreign Military 
Medical Officers from twelve countries. After the 



10 



U.S. NAVY MEDICAL NEWS LETTER 




1 

^ ' E ' I . > 




— 



Official U. S. Navy Photograph, Medical Photography Laboratory, 
U. S. Naval Medical School. 

First Row: CAPT J. H. STOVER, Jr. MC USN, CAPT Gihon Ferreira de 
ALMEIDA (Brazil), CAPT Aureliano REY Merodio (Argentina), CAPT 
Nelson Hora OLIVEIRA (Brazil), LT Mariano MAURA Reyes (Domin- 
ican Republic), CAPT Konstantinos RIZOS (Greece), CDR Antonino 
ALIQUO (Italy), CAPT J. M. HIRST MSC USN 

Second Row: CAPT Tong Pil CHOE (Korea), CDR Tso-an CHEN (China), LCDR J. 
Pico BROTONS (Spain), CDR Wessel R. VERMEER (Netherlands), 
LCDR Dang Tat KH1EM (Vietnam). CDR Jalal HAM1DI (Iran). CDR 
Ralf von GREGOR Y (Germany) 



greeting by CAPT John H. Stover Jr. MC USN, the 
Salutatory Address was delivered by RADM C. B. 
Galloway MC USN, Commanding Officer of the Na- 
tional Naval Medical Center. The visiting doctors were 
welcomed by CAPT F. E. Janney USN for the Chief of 
Naval Operations under whom this training program is 
established. This opening ceremony was most colorful 
with the various uniforms and flags of the countries 
represented by the trainees. 

The Commanding Officers of the Medical Center 
component commands and many other officers and 
guests were in attendance to extend the hospitality of 
the Navy to those specially selected Medical Officers 
from abroad. 

The 1964 program is a view in depth of Naval Medi- 
cine as it is practiced in the United Slates Navy. The 
curriculum contains numerous formal lectures and prac- 
tical experiences in U. S. Naval Medicine Ashore and 
Afloat, Diving and Submarine Medicine, Aviation and 
Space Medicine. Amphibious and Field Medicine, and 



elective clinical observation opportunities. Orientation 
visits will be made to military establishments, govern- 
mental agencies, industrial sites, and points of profes- 
sional and cultural interest. The group will be con- 
ducted to locations related to their studies in Washing- 
ton, D. C; Chicago and Great Lakes, Illinois; Detroit, 
Michigan; Williamsburg and Norfolk, Virginia; New- 
port, Rhode Island; New London, Connecticut; New 
York, New York; Camp Lejeune, North Carolina; 
Philadelphia and Johnsville, Pennsylvania; and Pensa- 
cola, Cape Kennedy and Key West, Florida. 

During the entire training program these Senior 
Foreign Medical Officers will become very familiar with 
the diversity of American life. The history of our 
country and the functions of our Judicial, Political, 
Economic and Social Institutions wilt be explained by 
recognized outstanding authorities in these and related 
fields. 

The course is expertly organized to develop a strong 
basis for improved understanding of these processes 



U.S. NAVY MEDICAL NEWS LETTER 



11 



among the countries of the free world through this occa- 
sion for sincere and mutual exchange of ideas. 

Graduation will be held on Friday. 4 December 1964 
when these Senior Foreign Medical Officers will receive 
their diplomas and depart for their respective home- 
lands. CAPT John M. Hirst MSC USN is Director of 
the 1964 program. 



POST RESIDENCY ASSIGNMENTS IN 
NAVAL HOSPITALS 

Cases have come to the attention of the Bureau in the 
past where medical officers have desired to remain at 
their Navy teaching hospitals after completion of resi- 
dency training in order to better prepare for their 
American specially board examinations. Because of 
the tirgent need for most of these officers elsewhere, 
very few such requests have been approved. Now. it is 
believed the future needs of the Navy will permit ap- 
proval of more of these requests. It stands to reason 
that not all residents completing training can be so 
assigned. Therefore, in order to establish a selection 
process among this group and to assure that the Navy 
will also benefit, the following plan has been approved 
by the Chief of Naval Personnel: 

(a) Any medical officer who is completing residency 
training in a naval hospital can request an extension of 
his duty as a part of the staff of that hospital for a 
period of one year after training: and 

(b) In that request such officer must agree to serve 
on active duty one year in addition to his period of 
obligated service (the one year at his hospital will be 
considered to be that additional one year). 

All requests submitted in accordance with the above 
must be accomplished prior to receipt of reassignment 
notification and they will be considered, based upon the 
following: 

(a) Commanding Officer's certification that the indi- 
vidual's services can be effectively utilized: 

(b) Commanding Officer's recommendation that the 
request be approved; and 

(c) The needs of the Navy. 

— Medical Corps Branch, Professional Div., BuMed. 

APhA military section achievement 

AWARD 

At the recent American Pharmaceutical Association 
Convention in New York City, the Military Section, 
with approval of the full Council of the Association, 
approved an Annual Award sponsored by the Eli Lilly 
Company, to be known as the "APhA Military Section 
Achievement Award." This award is to be given annu- 
ally to a member of the, Military Section who makes the 
best original contribution lo the Pharmaceutical litera- 
ture during the previous year. It will consist of a cash 
$500.00 honorarium and a suitable plaque to be award- 
ed at the Awards Night Dinner at the Annual Meetings. 



The judging committee for this award will consist of 
the Chairman of the Section and four other noted indi- 
viduals not employed by the Federal Government. 
Published articles must be submitted for consideration 
three months prior to the Annual Convention. 

All pharmacists on active or reserve duty with the 
Navy, in addition to pharmacists in other Federal 
Services, are eligible. 

NOTICE FROM THE SOCIETY OF 
MILITARY OTOLARYNGOLOGISTS 

The Society of Military Otolaryngologists will hold its 
13th Annual .Meeting on 20 October, at the Officers' 
Mess Open, Fifth Army Headquarters, I 660 Hyde Park 
Blvd., Chicago, at 6:30 p.m. Cost of the dinner will 
be $4 per person with refreshments on a pay-as-you- 
drink basis. 

The Society was founded in 1953 for the purpose of 
bringing logether all military otolaryngologists for the 
advancement of the science and art of otolaryngology in 
the military service, and for the furthering of profes- 
sional and social contacts between military otolaryngol- 
ogists. 

The organization now has 84 active members. This 
year they are writing to 61 eligible staff otolaryngologists 
and to 46 resident otolaryngologists to invite all who 
care to ( I ) apply for membership in the appropriate 
class and (2) irregardless of their status to attend the 
meeting mentioned above, at which time Dr. Clair M. 
Kos of Iowa City will be honored for his services to 
the group in particular and to otolaryngology in general. 

It is hoped that 106 of the 107 man eligible group 
(there's always one who doesn't get the word!) will 
promptly return a completed application form and fee, 
and that all who can will wangle TDY, TAD. AO's, or 
hops lo big CHI in October to greet and meet our guest 
of honor, and to attend the other incidental meetings 
that will be held there that week. Please indicate the 
number of dinner reservations you desire and enclose 
payment for these. Deadline for dinner reservations is 
October 8. 1964. The address is: 

CDR George R. Hart MC USN 
Box 223, U. S. Naval Hospital 
Philadelphia, Penna. 19145 
Sec-Trcas S. M. O. 

Preparatory School Scholarships to Be Awarded Young 
Men Desiring to Obtain Entrance to U. S. Naval 
Academy. The Society of Sponsors of the United 
States Navy awards scholarships to young men for 
preparatory schools to prepare them for entrance to 
the United States Naval Academy. 

Young men eligible are as follows: 
Category 1 — Sons of deceased, retired and active Navy 

and Marine Corps personnel 
Category II — Sons of personnel of the other military 

services 
Category III — Sons of civilians 



12 



U.S. NAVY MEDICAL NEWS LETTER 



(Sons of deceased and retired Navy and Marine 
Corps personnel shall have precedence over sons of 
active duty personnel who shall in turn, have precedence 
over sons of personnel of the other military services. 
Sons of military personnel shall precede applicants 
whose parents are not members of the Armed Forces). 

To receive such an award, an applicant must be ac- 
ceptable to the Scholarship Committee of the Society of 
Sponsors as to Character. Aptitude for the Naval Serv- 



ice, Scholastic Standing and Physical Fitness. The 
financial situation of his parents or of the applicant 
himself in case he is an orphan, must be such as to 
warrant the expenditure of the funds of the Society in 
making such an award. 

Application blanks may be obtained from: 

Mrs. Roy S. Benson 

Quarters "O" 

Navy Yard. Washington 25, D. C. 




DENTAL SECTION 



Report of a Case of Erythema Multiforme 



LCDR J. E. Hyde DC USN, LCDR D. T. Fenner DC VSN, and LT R. A. Murphy MC 
USNR. USS Yosemite (AD-19). 



Erythema Multiforme is an acute inflammatory dis- 
ease of unknown origin, usually involving the skin and 
mucous membranes. It is most frequently found in 
young adult males. The disease has a rapid onset and 
is normally accompanied by a high fever. Erythema 
Multiforme greatly resembles and must be differenti- 
ated from Vincent's Infection (trench mouth). Stoma- 
titis Medicamentosa, and Acute Herpetic Stomatitis. In 
the case described, the differentiation was particularly 
difficult because there were no skin lesions or lesions 
of mucous membranes other than the mouth. 

The patient reported to sick call complaining of an 
extremely painful mouth and bleeding lips and gums. 
Physical examination revealed a young well-nourished 
male, who appeared toxic and had a temperature of 
101.4 F. ' The lips were swollen, cracked, and bleeding. 
The lower half of his face appeared edematous. His 
breath had a marked fetid odor similar to that associ- 
ated with Vincent's Stomatitis. In the oral cavity, the 
buccal mucosa, the gingivae, and the hard and soft 
palate bore many ulcers. These ulcers were shallow 
and ranged in diameter from '.4 to one inch. Some of 
the ulcers were covered by a grayish pseudomembrane, 
which could be removed quite easily. There was greatly 
increased salivation and drooling from the commisures 
of the lips. The teeth and a large part of the gingivae 
were covered with materia alba. The rest of the physi- 
cal examination was essentially negative. 



The patient's history revealed that he had first 
noticed the onset of the symptoms three days previously, 
but that it had not been "too bad" until that morning. 
A tooth (No, 19) had been extracted nine days pre- 
viously, but there had been no post-operative complica- 
tions. He had had a "cold" two weeks previously for 
which he had taken "aspirin." He denied having been 
under any medication or of having received any im- 
munization injections recently. He had not eaten un- 
usual food. He denied having any allergies. He did 
admit to a history of "coldsores" whenever he had a 
cold. The family history was unrevealing. A tentative 
diagnosis of Acute Herpetic Stomatitis, with a secondary 
Vincent's Infection was made. A mucosal smear was 
essentially normal, as were the WBC and differential 
blood count, except for a slight rise in the eosinophiles. 

The patient was given 600,000 units Procaine Peni- 
cillin I. M. Stat and placed on a regimen of 250 mg 
(400.000 units) PenVec tablets q4h. and saline mouth 
rinses qlh. 

By 1 600 that evening, his temperature had risen to 
102.6 F. At 1630, 600,000 units of Procaine Penicillin 
were again administered I. M. and by 1920, the temper- 
ature had dropped to 99.8 F. 

On the second day. the patient was again examined. 
There was no marked change in his physical appear- 
ance, but the saline mouth rinses had washed away 
enough of the materia alba so that the appearance of 



U.S. NAVY MEDICAL NEWS LETTER 



13 



the gingivae could be better evaluated. Because the 
gingivae appeared normal, we felt that Vincent's Infec- 
tion was ruled out. The diagnosis was changed to DU 
(Erythema Multiforme ). By the third day the patient 
was afebrile and the swelling of the lower face had 
started to subside. Since the patient was limited in his 
ability to eat, and was to be maintained for a number of 
days on a liquid diet, Nonavitamins (one tablet TID) 
were prescribed. On the fourth day, Na.,HCO: ; mouth 
rinses were substituted for the NaCI rinses. By the 
sixth day, there was some improvement in the appear- 
ance of the oral tissues and the patient's general condi- 
tion was much improved. 

Since the patient was now feeling well enough to be 
able to move about, a consultation was arranged with 
the dermatologist at the United States Naval Hospital, 
Newport, Rhode Fsland. The diagnosis of Erythema 
Multiforme was confirmed by the dermatologist who 
prescribed Metacortin (Prednisone) for three weeks in 
diminishing doses (5 mg q. i. d for one week, 5 nig t. i. 
d for one week, and 5 mg b. i. d for one week). The 
remainder of (he recovery was rapid and uneventful. 
On the tenth day, the PenVee was discontinued and on 
the twelfth day the patient was discharged to duty. 

The patient has been seen a number of times within 
the four months following his return to duty. There 
has been no recurrence of the disease. Summary; A 
case of Erythema Multiforme has been discussed. This 
case was of particular interest because of the limitation 
of the lesions to the oral cavity, 

PERSONNEL AND PROFESSIONAL NOTES 

ADA Recognizes Electric Toothbrushes. The American 
Dental Association has announced recognition of two 
electric toothbrushes — manufactured by Genera! Elec- 
tric Company and E. R. Squibb and Sons — as "effective 
cleansing devices." It was the first time that the Asso- 
ciation had given such recognition to any electric 
toothbrush. In a statement published in the September 
1 issue of The Journal of the American Dental Associa- 
tion, the ADA Council on Dental Therapeutics classified 
the General Electric brush in Group A. The Council 
has authorized use of the following statement by the 
company: The General Electric toothbrush has been 
accepted (Group A) as an effective cleansing device for 
use as part of a program of good oral hygiene to supple- 
ment the regular professional care required for oral 
health. The Council classified the Squibb toothbrush 
in Group B and authorized use of the following state- 
ment by the company: The Broxodent toothbrush has 
been provisionally accepted as an effective cleansing 
device for use as part of a program of good oral 
hygiene to supplement the regular professional care re- 
quired for oral health. Group A consists of accepted 
products listed in Accepted Dental Remedies, published 
annually by the Council. Group B consists of products 
which, because of their relative newness, lack sufficient 



evidence for regular listing in Accepted Dental Rem- 
edies, but for which there is good evidence of usefulness 
and safety. The Council on Dental Therapeutics has 
emphasized that the distinction between Group A and 
Group B products is related to time and available evi- 
dence and not to quality or effectiveness. The Council 
also issued a general report on electric toothbrushes. 
"The powered toothbrushes that have appeared on the 
market have varied widely in their operating character- 
istics, their construction, their cost and their potential 
hazard either from electrical shock or from the possibil- 
ity of traumatizing (injuring) the oral tissues," the re- 
port said. "The competitive promotion of some of 
these devices has at times displayed a tendency toward 
exaggerated claims and unwarranted disparagement of 
the conventional manual toothbrush, There has also 
been a wide variation in the character and amount of 
clinical testing to which the several devices have been 
subjected." For these reasons, the Council said it had 
included electric toothbrushes in its evaluation program 
"in order to provide authoritative information to the 
dental profession, and general guidance and protection 
to the public." 

The Council emphasized that currently available 
clinical proof showed that [he two classified brushes 
had proven cleansing ability, but that there was not yet 
sufficient evidence for therapeutic claims by any brush. 
The Council said that "promotional claims for tooth- 
brushes (either manual or powered) should be limited 
to those of a cosmetic nature and to those associated 
with oral cleanliness as an aid in the prevention of some 
forms of periodontal disease." The Council added that 
"consumer advertising should not include claims relating 
to the treatment of existing oral disease because of the 
potential for harm if the device were used for this 
purpose without professional supervision." The Council 
report indicated that there was no proof that one type 
of motion in a powered brush was superior to another. 
In its present evaluation of powered brushes, the Coun- 
cil said it will consider the following four standards: 

1. As adequate evidence of technical safety, the de- 
vice must have been submitted to examination by and 
meet the requirement of an appropriate testing labora- 
tory such as listing by Underwriters Laboratory, Inc. 
This requirement may be waived for devices operating 
from non-rechargeable batteries of low voltage. 

2. Adequate evidence must be available from clinical 
investigations to show that unsupervised use of the 
device will not be harmful to oral hard or soft tissues 
or restorations. 

3. Adequate evidence must be provided from clinical 
tests to show that the device can be readily employed 
under unsupervised conditions by the larger segment of 
the public to provide a high degree of oral cleanliness, 

4. Claims for the device in labeling and in advertising 
to the public shall be limited to those related to oral 
cleanliness and the advertising shall avoid unwarranted 
disparagement of the conventional toothbrush. 



14 



U.S. NAVY MEDICAL NEWS LETTER 



Use of Resuscitation Devices. Resuscitators for use in 
Dental Clinics have been the subject of considerable 
discussion and correspondence within and outside the 
Defense Department. Since there appeared to be a de- 
gree of controversy and uncertainty as to both the need 
and type of resuscitators required in Dental Clinics, this 
office sought the advice and counsel of the National 
Research Council, National Academy of Sciences. 

After deliberating with anesthesiologists and dental 
members and considering the views of representatives 
from civilian and military dental professional groups, 
the Council made the following recommendations on 4 
November 1959: 

1. Dentists in the service clinics should receive peri- 
odic refresher training in resuscitative measures. 

2. The Dental Clinics should have a pre-arranged 
plan for management of respiratory emergencies. 

3. The use of a mechanical positive pressure or pos- 
itive-negative pressure cycling device in the management 
of dental respiratory emergencies is definitely not rec- 
ommended. 

4. The simplest pressures such as a bag, mask, and 
oxygen supply should be available. 

These conclusions represent the opinions of a repre- 
sentative group of knowledgeable people and provide 
appropriate advice and guidance as deemed applicable. 
(Excerpt from The Assistant Secretary of Defense for 
Health and Medical Progress Report for December 
1959). In view of this information, dental activities 
are advised that the item recommended for procurement 
to satisfy emergency resuscitative needs is "FSN 6505- 
975-3636 OXYGEN, USP, with TUBE and FACE 
MASK." (Submitted by CAPT L. M. Wallace DC 
USN, Field Branch, BUMED, Brooklyn, New York.) 
Navy Dental Corps Training Films. Navy Dental Corps 
training films currently available, with their catalogue 
number, date of production, and a short description, 
are listed to facilitate use by all interested individuals 
or groups. Civilian requests should be addressed to the 
Director, Medical Film Library, U. S. Naval Medical 
School, National Naval Medical Center, Bethesda, 
Maryland 20014. 

Department of Defense requests should be directed 
to the nearest Navy training film library. If this address 
is not immediately available' or the library is not able to 
supply the film, requests will be honored by the Medical 
Film Library, National Naval Medical Center, as indi- 
cated for civilians. 

All films distributed in 1964 and those to be released 
in the future may be obtained from the Medical Film 
Library of any Naval Hospital within the continental 
limits of the United States. The following films have 
been released in 1964: Periodontal Disease: Prevention 
and Early Treatment (1964) (Color, sound — 22 min.) 
MN— 9727. 

Summary: Develops the basic theme that the dentist 
must treat not only the teeth but also their supporting 
structures. Establishes three main rules: diagnose and 



treat periodontal disease early, consider periodontal 
response in all areas of restorative dentistry, and 
teach patients good oral physiotherapy; illustrates these 
rules with typical cases, explaining the progression from 
marginal gingivitis to periodontitis, and the periodontal 
considerations essential in the practice of the restorative 
specialties. Live photography, animation models. 
Many intraoral close-ups. 

Immediate Denture Service: Coordinated Management 
(1964) (Color, sound— 20 min.) MN— 9739. 

Summary: Demonstrates the collaborative effort of 
diagnostician, prosthodontist, surgeon and patient in the 
planning and consummation of immediate denture serv- 
ice. Emphasizes the importance of diagnosis, continuity 
of responsibility and instruction of the patient. Partic- 
ularly advocates conservative treatment, showing that 
alveolectomy is seldom necessary. 

Intraoral Roentgenography: Improved Equipment and 
Technique (1964) (Color, sound — 26 min.) MN — 
0774. 

Summary: Purpose is to acquaint dental personnel 
with the advantages of variable-KV roentgen ographic 
equipment and to demonstrate the superiority of films 
produced by the "long-cone" technique. Explains prin- 
ciples of roentgen-ray generation and characteristics of 
the ray. Emphasizes control of radiation exposure by 
filtering, use of fast film and increase of distance. Ex- 
plains use of increased kilovoltage for optimum pene- 
tration, control of radiation exposure and improvement 
of image quality. Illustrates in detail the placement of 
film to produce images with best anatomical accuracy, 
using the right-angle technique with the extended tube 
of "long cone." 

Preventive Dentistry: The Prevention of Oral Disease 
(1964) (Color, sound— 20 min.) MN— 9868. 

Summary: The prevention of dental caries and peri- 
odontal disease is the subject presented in this motion 
picture. By means of dental office scenes and animated 
drawings, factors responsible for these diseases are 
clearly described and illustrated in detail. Progression 
of the early stages of dental caries and periodontal 
disease to eventual loss of the teeth is discussed as con- 
sequences of the neglect of the care of the teeth and 
supporting structures. This motion picture is the first 
of a series dealing with a very challenging problem . . . 
that of educating the patient in preventive dentistry 
measures. The subject matter is prepared for ages 17 
to 35 but has value for younger audiences as well as 
parents of young children and is of utmost importance 
to all dental personnel. Attention is directed to dental 
problems most common to the given age group with 
the purpose of stimulating good habits for the preven- 
tion of those diseases responsible. 

Surgical Endodontics (1964) (Color, sound — ) 
MN— 9773. 

Summary: Taking a conservative point of view and 
maintaining the theme that endodontic surgery is an 



U.S. NAVY MEDICAL NEWS LETTER 



15 



adjunct to thorough root canal therapy, this film ex- 
plains the process of periapical inflammatory reaction 
and demonstrates three surgical corrective procedures: 
curettage standard root resection and resection with 
amalgam seal. In urging great caution in selection of 
cases for surgical management, the film first reasons 
that ideally the patient's own physiological defenses 
institute repair of periapical damages when root canal 
irritants have been removed and the space has been 
obliterated. The picture then shows techniques and 
precautions, to be followed when surgery does become 
necessary. 



A Sweet Tooth Can Spoil A Sweet Smile. A one-page, 
fold-out pamphlet, prepared by the Philadelphia County 
Dental Society, presents some interesting patient educa- 
tion information. These pamphlets are available, as 
long as the supply lasts, and make excellent waiting 
room material. They may be ordered, 25 at no cost, 
from the Council on Dental Health, Philadelphia 
County Dental Society, 17th and J. F, Kennedy Boule- 
vard, Philadelphia, Pa. Briefly, this is the material and 
manner presented: The human body requires 42 lbs. of 
sugar a year to maintain normal health. The average 
American consumes 144 lbs., or over 100 lbs. of excess 
sugar each year. Since the greatest damage to teeth is 
caused by between meal sugar-containing snacks, we 



should substitute fresh or dried fruits, unsweetened fruit 
juices, vegetables, or dairy products. 



CAPT S. E. Tande Participates at Conference. During 
the week of August 9th, CAPT S. E. Tande, DC USN, 
Head, Audio-Visual Department, U. S. Naval Dental 
School, National Naval Medical Center, Bethesda, 
Maryland, presented a talk entitled "Emergency Re- 
suscitation" at the Conference Workshop of the Inter- 
national Rescue and First Aid Association. CAPT 
Tande also monitored the U. S. Naval Dental Corps 
exhibit, "Mr. Disaster," during the 17th annual Con- 
ference, which was conducted at Bal Harbour, Florida, 
and attended by representatives from overseas, Canada, 
and the United States. 



Nedical News Letter Erratum Notice 

The information contained on page 34 of Volume 
44, Number 4, 21 August 1964 issue \\as partially in 
error. 

The figure 150 mg/ml (line 3) is corrected to 1.5 
mg/ml and the figure 145 mg/ml (line 7) is corrected 
to 1.45 mg/ml. (Appreciation is extended to RADM 
William M. Silliphant MC USN (Ret) for calling our 
attention to this error.) 



APPROXIMATE CARBOHYDRATE CONTENT OF COMMON FOODS 



Food 
Breads: 

White or rye 

Cinnamon bun with raisins 

Chocolate cake, 2 layer, iced 
Candies: 

Chocolate bar 

Chewing gum 
Carbonated Drinks: 
Fruits, Fresh: 

Apple 

Banana 
Fruits, Dried: 

Apricots, figs, prunes or dates 
Fruit Juices, unsweetened: 
Gelatin: 
Milk, plain: 
Nuts: 
Pie: 

Fruit 

Custard 
Spreads; 

Jam, jelly, marmalade 
Vegetables; 



Serving 

I slice 

average 
1 slice (1/12 cake) 

5 cent size 
I cent stick 
8 oz. 

1 medium 
I medium 

2-3 medium 

8 oz. 
Vi cup 
8 oz. 
% cup 

1 slice (1/6 med. pie) 
I slice (1/6 med, pie) 

1 tbs 
I serving 



Sugar Equivalent 



2 


tsp 


6 


tsp 


15 


tsp 


7 


tsp 


Vi 


tsp 


5 


tsp 


4 


tsp 


6 


tsp 


4 


tsp 


4-5 


tsp 


4 


tsp 


2 


tsp 


4 


tsp 


13 


tsp 


10 


tsp 


2-3 


tsp 


2-3 


tsp 



16 



US. NAVY MEDICAL NEWS LETTER 




OCCUPATIONAL MEDICINE 



The New Federal Employees Occupational 
Health Service Program 



John W. Macy, Jr., Washington D. C, Jour of Occupational Medicine, 6(7): 
July 1964. 



279-282, 



I welcome the formation of the Council of Federal 
Medical Directors for Occupational Health and its 
promise of close professional collaboration with the 
Civil Service Commission on behalf of a sound em- 
ployee health program in the federal service. The 
desire for an improved and progressive federal em- 
ployee health service program, extended to a larger 
proportion of the federal work force, is something the 
Commission has shared with occupational physicians 
for a long time. While legislative authority for occupa- 
tional health services has existed since 1946, the law 
and the 1950 statement of policy did not carry strong 
executive interest and support. As a result, a few fed- 
eral agencies developed extensive programs, some 
agencies provided more limited programs, and many 
did little or nothing. 

The new policy statement, which has been developed 
jointly by the Bureau of the Budget and the Civil 
Service Commission, is a tremendous step forward. 
First of all, it states that each department and agency 
head shall (with certain conditions) establish an occu- 
pational health program. This is significantly different 
from the 1950 statement which said they are encouraged 
to do so. Second, it specifies clearly the services such 
programs shall include. The result will be a reasonably 
uniform, substantial, government-wide occupational 
health service program, which is long overdue. 

The objectives of this program are entirely consistent 
with President Johnson's drive for efficiency and econ- 
omy in government administration, for they are, basi- 
cally, the improvement of employee morale and produc- 
tivity. The program is in no sense a "fringe benefit"-, 
it is a program for the protection and conservation of 
our most precious resource — the human resource. 

U.S. NAVY MEDICAL NEWS LETTER 



No one questions that it is economically sound to 
spend time and money on the maintenance of property 
and equipment in which we have made an investment. 
We take pains to keep our buildings, machines, cars, 
and furniture in the best possible condition. We make 
the biggest and most important investment of all in our 
human resources, and yet we have paid a minimum of 
attention to "maintenance." 

For a long time the federal service has kept abreast 
of — and in some areas has been ahead of — private in- 
dustry in progressive personnel administration. We are 
continually making refinements and improvements in 
merit-system recruiting, competitive testing, job classi- 
fication, in-service training, career development, and the 
(ike — but we have tended to forget the importance of a 
sound mind in a sound body. In this respect, we have 
trailed far behind private industry, as industrial physi- 
cians well know from their professional associations. 

Historically, the government seems to have taken an 
interest in the health of its employees only at the very 
beginning and the very end of their careers (at appoint- 
ment and at retirement) with nothing in between unless 
an employee had the misfortune to suffer injury or ill- 
ness on the job. Now, at last, we are moving toward 
filling that long, long gap. 

I do not mean to suggest that that gap has been en- 
tirely empty up until now. If that were the case, there 
would be no such thing as the Council of Federal Medi- 
cal Directors for Occupational Health. It is true that 
since the enactment of the 1946 legislation progress has 
been made toward providing some measure of occupa- 
tional health services to substantial numbers of Federal 
employees. Nevertheless, a great many employees still 



17 



have no health facilities available to them where they 
work. 

The Bureau of the Budget recently made a study of 
2,346,700 employees to determine the size of the group 
not covered. Slightly more than half of the total num- 
ber were in the Department of Defense, the Veterans 
Administration, and the Department of Health, Educa- 
tion, and Welfare. The Department of Defense re- 
ported that health services are available to all of its 
employees at locations where there are sizable concen- 
trations of personnel. The Veterans Administration has 
some health facilities for almost all of its employees. 
The Department of Health, Education, and Welfare 
indicates that all of its employees in Washington and 
64% of those in the field are served by health units. 
Of the remaining 1,126,400 employees in the other 37 
reporting agencies, health services are available to about 
37%, or 417,600. The remaining 708,800 employees 
have no health facilities available. 

Some of the employees not covered are working in 
small groups and at isolated work locations. It does 
not seem economically feasible at present to extend 
services to (hem. Others, however, are working in 
metropolitan areas where there are a number of federal 
installations. We believe that basic occupational health 
services can be extended to most of them through the 
development of cooperative programs. 

The New Program 

Before discussing details of this new policy directive 
I want to emphasize two general principles. First, this 
program is concerned with the health of employees in 
relation to their work: it is just as pertinent to their 
efficiency and productivity as any other qualifications, 
and is therefore the legitimate and necessary concern of 
the employer. The personal health of the employee is, 
of course, his personal responsibility, and this program 
does not intrude into that area. 

Second, the relationship between this program and 
the Federal Employees Compensation Act is clarified. 
The Compensation Act provisions are not changed, but 
the directive states a coordinated policy for agency 
operations under the two authorities and it goes beyond 
the 1950 Policy Statement (which it replaces) in build- 
ing toward a modern-day occupational health service. 
Agency programs to eliminate work hazards and health 
risks have generally emphasized accident prevention; 
this program emphasizes preventing and controlling 
such health risks as occupational disease. 

Each agency is to provide employee health services 
of the scope specified for all employees who work in 
groups of 300 or more in the same or nearby buildings. 
Services may be provided for smaller groups where 
warranted by working conditions involving special 
health risks. 

The agency head, after consultation with the Public 
Health Service and the Department of Labor as to per- 
tinent standards, is to establish the health program in 



the manner best suited to the agency situation: by using 
the agency's own professional staff and facilities; by 
contracting with other federal agencies having such 
staff and facilities; or by establishing an agency staff or 
by contracting with nonfederal physicians. 

The General Services Administration and the Post 
Office Department have indicated their willingness to 
carry out the special functions of providing suitable 
space for agency health unit facilities. Jn those cases 
where special occupational health risks require health 
services for groups smaller than 300, the services will 
normally not be set up in federal space, unless other 
suitable sources are not available. 

The new program clearly states the nature of the 
occupational health services that are to be provided. 
The extent of each of those services is to be determined 
by the agency head on the basis of the number of em- 
ployees to be served and the conditions under which 
they work. That determination will, in turn, decide the 
size and the composition of the professional staff re- 
quired, and what kind of facilities will be provided. 
Wide variation is to be expected, since the employee 
groups served will range from 300 to several thousand. 

The occupational health services are to be "uniformly 
composed of and limited to" the following: 

1. Emergency diagnosis and treatment of injury or 
illness that may occur during working hours. This 
service is basic, and is to be provided in all cases either 
by the federal or contract professional staff, or by tak- 
ing the employee to the nearest community doctor or 
hospital. 

2. Health examinations of two types: first, the pre- 
employment examinations required of persons selected 
for appointment, which at present must be paid for by 
the person selected unless he can make arrangements 
with a federal medical officer. It is anticipated that the 
number of cases in which appointment is made subject 
to later medical examination — which has been a neces- 
sary evil in the past — will be greatly reduced by this 
provision. Second, any examinations after appointment 
that the agency head may require of designated em- 
ployees in order to evaluate their health status in rela- 
tion to present or proposed work assignments. Such an 
examination may be authorized if necessary to attain 
maximum efficiency and productivity and to assess the 
effect of the work or working conditions on the em- 
ployee's health and the effect of the employee's health 
on his work. These needs may arise in connection with 
changes in assignments or changes in an employee's 
physical condition. 

3. Administration of treatments and medications pre- 
scribed in writing by the employee's personal physician 
and furnished by the employee, or by a physician pro- 
viding medical care under the Federal Employees Com- 
pensation Act. This service is not mandatory; it should 
be provided if, in the judgment of the physician re- 
sponsible for the federal health service, there is sufficient 
staff, time, and equipment, and if the treatment is 



18 



U.S. NAVY MEDICAL NEWS LETTER 



reasonably necessary to maintain the employee at work. 

4. Referral of employees (at their request) to private 
physicians, dentists, and other community health re- 
sources. 

5. Three types of preventive services: a. Appraising 
health hazards in the work environment and reporting 
them to agency management as an aid in preventing and 
controlling health risks, b. Providing health education 
to encourage employees to maintain personal health and 
fitness, c. Providing specific disease-screening examina- 
tions such as chest x-ray, a tension-test for glaucoma, 
and the like, as well as immunizations. When these are 
required by the agency, all costs will be paid by the 
agency. When mass screening examinations or im- 
munizations are provided by the agency on a voluntary 
basis, the employees will pay for the materials and 
medications. 

Summary. This, then, is the framework within which 
the new federal employees occupational health service 
program is to operate. To recap briefly, it includes 
on-the-job emergency treatment, pre-employment and 
fitness-for-duty examinations, treatments prescribed by 
the employee's own physician, referrals to community 
health resources, and preventive programs. It is that 
last-named service that is the one not previously pro- 
vided and I consider it a most significant gain. In the 
program it is clearly required (1) that the health serv- 
ices shall be under the direction of a licensed physician; 
(2) that nursing services shall be provided by registered 
professional nurses; and (3) that to the maximum ex- 
tent possible these personnel be qualified in occupational 
medicine and nursing. Having the services under the 
direction of a physician does not mean that there must 
be a physician stationed at every health unit. It means 
that a physician at a suitable location (such as agency, 
regional, or district headquarters) shall be in charge. 

It is estimated that about 2000 new health service 
units will be established as a result of this expansion. 
This will eventually require the employment of addi- 
tional federal medical officers. The number required 
will depend upon the scope and pace of program de- 
velopments in the several agencies. 

An amusing sidelight on this subject — and a further 
illustration of the fact that in Washington all informa- 
tion is public information — is that the Civil Service 



Commission has already received at least one call from 
a nurse asking "Who's doing the hiring?" I hope this 
is a good omen. I hope that the federal employees 
occupational health service program will be sufficiently 
interesting, progressive, and challenging that qualified 
doctors and nurses will be eager to take part in it. 

Those already in this important work will have a new 
challenge before them: to organize and operate the best 
possible employee health service in keeping with the 
requirements of this program and within the $10/ em- 
ployee annual limitation on expenditures. (This limita- 
tion, by the way, has a floor of $10,000 annually for 
units with more than 300 but not more than 1000 
employees. ) 

I anticipate protests that some facilities already pro- 
vide more extensive service than this program specifies. 
I know that is true in some cases. But in order to 
achieve the full benefits to the government which this 
program is potentially capable of achieving, it must be 
a consistent program covering as large a percentage of 
the federal work force as possible. As such, it will 
play a constructive role in government programs for 
hiring the handicapped and older workers; it will con- 
serve sick leave; and it will reduce group health insur- 
ance costs. These benefits, in addition to the more 
obvious and direct results — such as better mental and 
physical health, higher morale, and a more vigorous, 
efficient, and productive work force — should inspire and 
stimulate all of us to new and determined efforts. 

In keeping with the responsibilities specifically as- 
signed to me, I will see that all possible assistance is 
provided to agencies in establishing or improving their 
health programs and to agencies taking joint action to 
set up cooperative health services. 

To be sure, there are some limitations in the author- 
ization, and there will be limits in agency resources. 
But more important is that there will eventually be 
"live," functioning occupational health service programs 
— built on sound AMA standards — in some 2000 work 
locations that have had nothing, and that substantial 
improvements will be made in countless others. This is 
an opportunity to move ahead at a more affirmative and 
rapid pace with clear direction toward goals of signifi- 
cant meaning to those who work for the government in 
behalf of all the American people. 



Prospects of successful vector control by genetic manip- 
ulation have been considerably enhanced by recent 
studies of meiotic drive. This phenomenon causes cer- 
tain loci or chromosomes to be present disproportion- 
ately often in the gametes contributing to each gen- 
eration. Thus, even if a chromosome carries a lethal 
or deleterious gene, it may tend to increase in the 
population if it simultaneously exhibits meiotic drive. 
—WHO Chronicle 18(2): 45, February 1964. 



The population/ doctor ratio in the Eastern Mediter- 
ranean countries ranges from about 1000 to 1 to well 
above 30,000 to 1. Two-thirds of the Region's popula- 
tion live in countries where it is 20000 to 1. Drastic 
replanning of medical education is needed to make up 
for the shortage of doctors, since most of the 31 med- 
ical schools in the Region are stretched to the limits of 
their capacity. — WHO Chronicle, 18(3): 106, March 
1964. 



U.S. NAVY MEDICAL NEWS LETTER 



19 



The Concept of Biological Variation in Audiometric 

Reference Levels 

Kenneth C. Stewart MS, Journal of Occupational Medicine, 6(7): 293-296, July 1964. 



Davis and Kranz have summarized much of the dis- 
cussion relative to the establishment of new reference 
levels for pure-tone audiometric threshold measure- 
ments. These discussions suggest to us a basic problem 
which is encountered in the establishment of any such 
zero reference level. We recognize two distinctly dif- 
ferent aspects of this basic problem. One is associated 
with the manufacture and physical calibration of the 
audiometric test instrument, and the other deals with 
the description and interpretation of the decibel hearing 
levels which are obtained from the use of an instrument 
which is properly calibrated with respect to some ref- 
erence level. This first aspect of this problem — that is, 
the physical calibration of the audiometer with respect 
to some reference point — does not present any insur- 
mountable difficulty. Any properly equipped acoustic 
laboratory, staffed with adequately trained people, can 
handle physical calibration of the instrument relative to 
whatever standards are adopted. The second aspect of 
the problem presents difficulties that are not easy to 
overcome. The practice of describing decibel hearing 
levels, which appear on the audiogram form as devia- 
tions from the accepted standard reference sound pres- 
sure level at each frequency, often results in misinter- 
pretation of the individual pure-tone threshold data. 
Current procedures and past practices, it appears to us, 
place too much emphasis on the importance of "audio- 
metric zero" in the interpretation of test data. This 
problem is evident with the current standard zero levels 
and it will not be solved with adoption of the proposed 
new "international standard zero reference level." This 
paper is concerned, therefore, with the second aspect of 
the problem. It seems to us that, in our attempt to 
establish more adequate "zero levels" for audiometric 
norms, our attention has not been directed toward the 
fundamental issues of the problem. Perhaps we should 
emphasize the basic biological variations of man rather 
than some measure of the central tendencies of groups 
when we evaluate an individual's hearing sensitivity for 
pure tones. Looking at the problem from this point of 
view, there is, in fact, no such thing as "audiometric 
zero" if audiometric zero is presumed to represent a 
"point" indicative of normal hearing. All that this 
means, of course, is that normal hearing sensitivity for 
pure tones is better described as a range of values than 
as a point value. We recognize that audiologists, otol- 
ogists, and others who are trained in the clinical aspects 
of hearing evaluation are aware of this fact. But we 



are convinced that, frequently, the thinking of many 
people involved in the interpretation of hearing test 
results, is influenced by our current practice of measur- 
ing and plotting pure tone sensitivity thresholds relative 
to a "normal" zero point. Whether that zero point is 
the current American standard or the proposed new 
standard makes little difference in this respect. Part of 
the difficulty centers around the fact that many different 
kinds of individuals, with varied kinds of training and 
backgrounds are necessarily involved with hearing test- 
ing and evaluation of hearing abilities. And, because of 
this, the terms used often mean different things to dif- 
ferent persons. Let us not assume that we all know 
that "normal" pure tone hearing sensitivity is really a 
range of values around some zero point, whatever mean 
or median or modal value that "zero" might represent. 
Let us plan our measurements and the description of 
our data so that we can see where the individual's hear- 
ing sensitivity lies with respect to the best ranges which 
we can develop for the normal population. Industrial 
medical directors, audiologists, otologists, lawyers, com- 
pensation boards, and many others have a stake in our 
decisions. 

One possibility which could lead to a clearer inter- 
pretation of pure-tone threshold test data would require 
that we do the following: 1. Abolish the "zero" hearing 
level altogether from the audiometer and the audiogram 
form, leaving this "zero" in the physical acoustics lab- 
oratory. 2. Choose an audiometric calibration reference 
level which is lower in intensity, at each frequency, 
than the most sensitive pure-tone thresholds that we 
would encounter in real people of any age. This would 
eliminate negative numbers from the audiogram and 
eliminate the possible confusion resulting from interpre- 
tations that are frequently made which imply "better 
than normal" hearing sensitivity for thresholds having 
minus values. The audiometer could be calibrated 
against a reference level which would be equivalent to 
current audiometric zero, minus 30 db. This could be 
easily accomplished in the physical laboratory. It 
should be emphasized here, that this is a "calibration" 
process involving a problem for the laboratory and that 
while this reference level for calibration purposes is 
still based on a point value, it is not emphasized on the 
audiogram form. 3. Eliminate the "O" on the audio- 
gram form. The top line of the audiogram form would 
be designated as the "lower bound." Here we have 
borrowed a concept from mathematics. In our usage 



20 



U.S. NAVY MEDICAL NEWS LETTER 



of the term, "lower bound" means a sound pressure low 
enough that no individual can hear it. The ordinate of 
the audiogram form would be scaled in decibels above 
lower bound. Since lower bound is still based on a 
concept of normal modal values, these decibels will be 
of the "hearing level" type. In other words, we are 
still utilizing a physiological, rather than a physical 
reference. This procedure would be followed rather 
than the utilizing of decibels of sound pressure level, 
which would change too drastically the shape of the 
sensitivity curves we are accustomed to evaluating. 
4. Print on the audiogram form the curves representing 
the median and the first and third quartiles for a given 
age class. These quartiles would be plotted in decibels 
of hearing level above lower bound. Population norms 
in terms of medians and first and third quartiles would 
be used. Norms for different age groups would, of 
course, vary from one to another, and norms should be 
developed for each 5- to 10-year age group. Thus, 
when a pure-tone hearing threshold test is accomplished, 
the results would be plotted on an audiogram form con- 
structed for the age group into which the particular 
individual falls. A separate audiogram form, for ex- 
ample, would be used for each 5- or 10-year age group 

with normal medians and quartile ranges for that age 

group printed on the form. In this case, one which 
would be used for plotting the audiogram of an indi- 
vidual between 31 and 36 years old. It should be 
emphasized here that we are not recommending that 
the specific quartiles become the national or interna- 
tional reference norms. These values, while based upon 
accurate experimental findings for a fairly large group 
of people, are used here for illustrative purposes only. 
The individual pure-tone threshold results were taken 
from a real individual who had been subjected to noise 
exposure over several years. A comparison shows a 
major advantage of this method of displaying pure-tone 
thresholds. The examiner can see where this individual's 
thresholds lie with respect to the median thresholds of 
a group of normal hearing, n on noise-exposed individuals 
of his own age class. He can also see where this indi- 
vidual's thresholds lie with respect to the range of this 
group of normals. 

We should emphasize that, while the audiometers are 
still calibrated with respect to a physiological "zero" 
point, the reference against which the individual's pure- 
tone sensitivity thresholds are compared is the partic- 
ular population norm (median, first, and third quartile) 
printed on the audiogram form. 

As previously indicated, population norms must be 
developed for each 5- or 10-year age group. This is 
based upon normal values, which are used here for 
illustrative purposes. 

There is one other possible modification for recording 
the test data, which would eliminate an aspect of cur- 
rent procedures that confuses many people. The popu- 
lation norms and the test results could be plotted in 
exactly the same way except that lower bound would be 

U.S. NAVY MEDICAL NEWS LETTER 



at the bottom rather than the top of the audiogram 
form. Much confusion is generated, even among audi- 
ology students and others, by the use of the term, 
"raised threshold," when a raised threshold represents a 
threshold which is plotted lower on the audiogram form. 
Plotting the data from the bottom up would make for 
more consistency in the language used to describe 
threshold results. In this case a "raised" threshold is 
also "raised" on the form. It is possible that this par- 
ticular modification might result in some confusion for 
awhile because of our customary interpretation of audi- 
ogram shapes such a "flat and sloping," etc.; however, 
as clinicians and others become more accustomed to 
this procedure it should result in less confusion in 
the language used to describe abnormal pure-tone 
thresholds. 

A few final observations with respect to the recom- 
mendations we have made are as follows. 

First, these recommendations suggest a method of 
recording individual pure-tone threshold data which 
we feel would be of help for large numbers of people 
from various disciplines who are concerned with in- 
terpretations of audiometric data. We feel these pro- 
cedures would help these people to view pure-tone 
audiometric test results more realistically because they 
emphasize the biologic variations of man. We observe 
at least two kinds of biologic variation in man's pure- 
tone hearing sensitivity. One is the variation that is 
present among individuals of similar ages; the other, 
the variation that occurs among individuals of differing 
ages. Our proposals recognize and emphasize the ex- 
istence of these variations in the interpretation of pure-, 
tone threshold results. 

We wish to recognize that this paper has not dealt 
with the development of population norms — except to 
suggest that normal ranges as well as normal measures 
of central tendency should be developed for various age 
groups. The method which we have suggested for de- 
scribing an individual's pure-tone threshold data will, 
however, be compared against whatever normative data 
are developed. And any alteration in norms, now or in 
the future, will not alter the manner of interpretation of 
individual pure-tone thresholds. 

We also wish to recognize the fact that these recom- 
mendations do not change the nature of problems faced 
by the highly trained clinical audiologist and otologist, 
who utilize pure-tone threshold test results for diag- 
nostic purposes. It is obvious that the problems in the 
clinical diagnostic setting, relative to interpretation of 
these test results in terms of specific ear pathology, 
disease entities, and the individual's social and com- 
municative handicap, involve concepts which are per- 
haps independent of the manner in which the test data 
are presented. We feel, however, that the person who 
is highly trained in areas of clinical audiologic evalua- 
tion would find our proposed procedures for calibration 
and data presentation entirely compatible with respect 
to his needs for evaluating the individual's handicap 



21 



from pure-tone data. This person would likely have 
little difficulty in adjusting to a new method of describ- 
ing pure-tone threshold data. On the other hand, many 
people, particularly those working with large industrial 
populations, may look at the interpretation of pure-tone 



: threshold data a little differently — and we believe more 
realistically and with less confusion — if we modify our 
procedures along the line we have suggested. And we 
would eliminate at least some of the confusion centering 
around the meanings of audiometric "zeros" based upon 
measures of the central tendencies of population groups. 



Cadmium Poisoning - California 



W. B. Walshe, Morbidity and Mortality Weekly Report, U. S. Department of Health, 
Education, and Welfare, Public Health Service, 13(31): 267, 7 August 1964. 



From 30 - 45 minutes after drinking pink lemonade, 
23 school children, aged 5 to 9, experienced abdominal 
cramps and vomiting in an outbreak due to cadmium 
contamination. All recovered within 48 hours. The 
severity of symptoms correlated with the amount of 
lemonade consumed. Nine other children, who only 
tasted or consumed small amounts of the lemonade, 
did not become ill. Each child brought a lunch from 
home; the lemonade was the only food common to all 



32. The lemonade was prepared by adding the proper 
amount of city water and ice cubes to 3 cans of com- 
mercially prepared concentrate. The mixture was 
placed in a 3-gallon cadmium plated war surplus con- 
tainer for the 3Vi hour interval between preparation 
and serving. 

Laboratory analysis of a sample of the remaining 
lemonade revealed 21 parts per million of cadmium, a 
dosage considered sufficient to cause the symptoms in 
the children. 



Asbestos Exposure During Naval Vessel Overhaul 



William T. Marr, American Industrial Hygiene Association Journal, 25(3): 264-268, 
May -June 1964. 



Problem 

The Long Beach Naval Shipyard insulation shop has 
60 to 80 employees working primarily aboard ship 
applying insulation containing asbestos to the steam 
power plants. Five employees, averaging 15 years ex- 
posure, have retired on disability compensation due to 
asbestosis. One employee, after 10 years employment 
as a pipecoverer and insulator, received disability com- 
pensation for seven years prior to his death in 1962. 
Extensive physical examinations and autopsy reports 
leave no doubt his death was due to asbestosis. He 
worked mostly on farms and in restaurants before his 
employment in the shipyard and denied any previous 
employment in a dusty trade. 

Breathing asbestos fibers, usually over a period ex- 
ceeding 10 years, causes this insidious industrial disease. 
A non-productive cough and progressive shortness of 



breath that can lead to disability are the most striking 
symptoms. 

This report covers: (a) material used, (b) working 
environment, (c) fiber counts, (d) x-ray findings, (e) 
discussion, and (f) summary. 

Material 

Asbestos is a commercial name applied to several 
varieties of fibrous minerals. These varieties are two 
dinstinct mineral groups, serpentine and amphibole, 
that differ considerably in composition and physical 
properties. Chrysotile, the fibrous form of serpentine, 
comes from Canada and constitutes about 95% of the 
total world production of asbestos. It is a magnesium 
silicate with iron, nickel, manganese, or aluminum often 
replacing part of the magnesium. The fibrous form of 
amphibole has four principal varieties, amosite, an- 
thophyllite, tremolite, and crocidolite. These four are 



22 



U.S. NAVY MEDICAL NEWS LETTER 



various silicates of iron, calcium, magnesium, and 
sodium. 

The replacement of one element by another in vary- 
ing proportions is a unique characteristic of asbestos 
causing a change in its physical properties. For ex- 
ample, machinery crushes chrysotile into fine soft silky- 
feeling fibers which are strong, flexible and can be 
woven into cloth. Amosite, which comes from South 
Africa, has long coarse fibers suitable for a blanket-type 
of insulation material. Amosite has been used in large 
quantities on naval ships since before World War II. 
Other than amosite, the amphibole mineral type of 
asbestos is weak and brittle. 

Most authorities believe that all types of asbestos can 
cause asbestosis. Medical science has not conducted 
sufficient research to determine the possible different 
effects of the mineral or which variety is the most 
hazardous. 

Employees in the insulation trade also use fiberglass, 
magnesia, diatomaceous earth, and other inert sub- 
stances that can complicate air sampling and the ex- 
posure hazard. Shipboard insulators use about ten dif- 
ferent types of insulation material containing different 
varieties and a varying quantity of asbestos. Table I 
gives a list of material used in shipboard insulation and 
its composition. The table also shows the percentage 
of time the employee works with the material and his 
exposure in millions of particles per cubic foot. 

Working Environment 

These employees, known as pipecoverers and insu- 
lators, face a potential exposure to asbestos fibers in the 
insulation shop and on board ship. 

Employees in the shop make pads shaped like small 
pillows for easy installation and removal from shipboard 
fittings, control valves, and pipe joints. A bolt of as- 
bestos cloth is on a roller at the end of the layout and 
cutting table. Directly over the bolt a water spray sys- 
tem allows water to dampen the cloth as an employee 
draws it on the table. The employee measures and 
marks the material into appropriate sizes and cuts it 
with a rotary electric hand cutter. Another worker 
then stitches the cloth on a power sewing machine and 
passes it to another table where fiberglass is cut to size 
and stuffed into the opening. Finally, an employee 
closes the pad by sewing, trims it with a power cutter, 
and attaches rings to aid in the installation aboard ship. 
The cloth remains damp during the work process mak- 
ing dust control methods relatively easy in the shop. 
General exhaust ventilation operates continually, assist- 
ed by large doors and windows allowing for cross- 
ventilation. Aboard ship pipecoverers and insulators 
perform a great variety of installations in most com- 
partments, especially in the firerooms and enginerooms. 
These men wire insulation block and insulation pipe 
sections in position around machinery and pipe. They 
make the surface smooth first by mudding with 85% 
magnesia plaster and then wrapping with asbestos cloth 
glued in position with a fire retarding waterproof ad- 



hesive. The amosite blanket, rarely used now, was 
generally used rather than preformed blocks and pipe 
sections until 1962. Employees apply rockwool mud 
to this amosite blanket followed by portland cement and 
asbestos cloth to form a smooth finish. They apply 
glass sheets to ventilation ducts and wrap it with fiber- 
glass or asbestos cloth. These men wrap fiberglass 
around fittings, control valves, and pipe joints, then 
attach the pads from the shop into position. 

During ship overhaul, repair, and remodernization, 
pipecoverers and insulators remove all the various types 
of insulation they have applied. As shown in Table I, 
this small portion of time spent in removing excessively 
dry insulation gives a high exposure to asbestos dust. 

Adequate ventilation for pipecoverers and insulators 
is rarely possible with our present ventilating system, 
which consists of 3,600 cfm exhaust fans with connec- 
tions for four 5-inch flexible ducts. These portable ex- 
haust fans are usually placed on the main deck and 
flow at each exhaust-duct entrance varies from 800 to 
1500 lfm depending on the work process. This present 
exhaust system designed especially for welding and 
burning work is not adequate for our pipecoverers and 
insulators because their work processes and work posi- 
tions vary. 

Dust control by use of water during shipboard work 
appears to be practical only during application of amo- 
site, a material seldom applied in our shipyard because 
of the excessive dust it causes during removal. The 
best protection for these employees is to avoid careless 
creation of dusty conditions by the use of damp mate- 
rial when possible, and the wearing of dust respirators 
constantly. 

Fiber Counts 

There are no established figures for a maximum al- 
lowable concentration of asbestos fibers in pipe cover- 
ing operations or for short duration massive exposures. 
Because study in a textile mill in 1938 found no cases of 
asbestosis where the count by impinger light field was 
below 5 mppcf, this figure became the recommended 
maximum allowable concentration. An asbestos opera- 
tion in Canada has had no new cases of asbestosis in 15 
years where the particle count is below 1 mppcf for 
dust below 10 microns. One U. S. industry uses 5 
mppcf below 10 microns and 1 mppcf above 10 microns 
as their MAC. 

Pathologists find fibers exceeding 400 microns in 
lungs during autopsy. These long fibers do not settle in 
air as rapidly as spherical particles. They are less than 
one micron in thickness and their needle-like form 
allows them to stand on end and work down into the 
lungs, 

The Saranac Laboratory experiments by animal ex- 
posure to asbestos indicated that asbestosis is a me- 
chanical rather than a chemical action. The research- 
ers also considered fibers greater than 10 microns the 
most harmful. This is not in agreement with recent 



U.S. NAVY MEDICAL NEWS LETTER 



23 



TABLE I 



Materials and Exposures in Shipboard Insulation Jobs 



Material 

(Used aboard ship by pipecoverers 

and insulators) 



1. 100% Amosite asbestos blanket 



Percentage of 

working time 

aboard ship 

(with each 

material) 





Installing 


rarely 




Removing 


3.0 


2. 


85% Magnesia and 15% amosite asbestos 
blocks and pipe sections 






Installing 


38.0 




Removing 


1.5 


3. 


Calcium silicate and 10% amosite asbestos 
blocks and pipe sections 






Installing 


42.0 




Removing 


2.0 


4. 


100% Chrysotile asbestos filler and binder 






Installing 


1.5 




Removing 


0.5 


5. 


15% Chrysotile and 85% rockwool filler and 
binder 






Installing 


1.5 




Removing 


0.5 


6. 


80-95% Chrysotile asbestos cloth 






Installing 


8.0 




Removing 


0.5 


7. 


Fiberglass 






Installing 


1.0 




Removing 


rarely 



Exposure Concentrations 

(length of exposure time varies from 

minutes to hours) 

particle range in microns fiber range in 

microns 



2-5 
mppcf 



1.4-3.0 



1.4-6.0 
0.8-10 



0.9-2.8 
0.4-1.7 
mixed as 
cement 
0.9-4.9 

mixed as 
cement 
0.8-4.7 

0.3-1.8 
0.2-1.9 



5-10 
mppcf 

Installed 
damp 
1.6-2.0 



0.1-0.4 
0.7-2.0 



0.2-3.0 
0.4-0.9 

and applied 

wet 

0.9-1.6 

and applied 

wet 

0.7-1.7 

0.2-1.4 
0.5-2.0 



3-60 
mppcf 



0.5-8.0 



0.1-1.8 

tr.-l-2 



trace 
trace 



trace 



trace 

trace 
trace 



studies in South Africa where authorities consider fibers 
less than 5 microns the most harmful. 

Dust counts, taken with the Bausch and Lomb Dust 
Counter, appear in Table 1. The low counts on sam- 
pling do not appear to give an adequate idication of the 
actual hazard. During sawing of blocks and pipe sec- 
tions and removal of old insulation, the work environ- 
ment appears extremely dusty. Respirator filters often 
clog after an hour's work removing insulation. Fibers 
from 3 to 60 microns in length received special atten- 
tion during this study. If fibers were present but count 
revealed less than one mppcf, they appear in Table I as 
a trace. 

X-ray Findings 

It is common practice for industrial hygienists to use 
information from periodic physicals to assure them- 
selves that exposure controls are adequate. X-ray 
examinations on new employees in asbestos are not of 
value for this assurance; on the contrary, this informa- 
tion can be extremely misleading as it usually takes a 
minimum of seven years exposure for cases of asbestosis 
to develop. It also appears that some people are sus- 
ceptible while others escape harm during the same 
exposure. 



A medical team surveyed five shipyards in 1945 to 
investigate the health hazard due to insulation work. 
Only three cases of asbestosis appeared in 1074 x-ray 
examinations. These three employees had worked in 
asbestos material for more than 20 years. Insulation 
material and work methods have remained essentially 
the same since that study, The greatest change, started 
right after the war, is the removal of insulation during 
overhaul and repair. Many of our employees now have 
over 20 years in the insulation trade in contrast to the 
survey in 1945 where only 51 of the 1074 employees 
had over 10 years experience in insulation work. 

Discussion 

The world's consumption of asbestos has increased 
from 500,000 tons in 1942 to 2,400,000 tons in 1961. 
Recent studies recognize asbestosis as a serious health 
hazard. Asbestos exposure during shipboard insulation 
differs from exposure in mining and manufacturing 
processes of this material. In these industries employees 
usually continue at one job with the same material and 
their exposure is relatively constant. This is not true 
for shipboard insulation where the pipecoverers' and 
insulators' work location, work position, and material 
constantly change. Under these conditions it is impos- 



24 



U.S. NAVY MEDICAL NEWS LETTER 



sible to determine the exposure of the employee without 
spending hours in observation and sampling. Samples 
taken as in Table I are only bases for discussion con- 
cerning their exposure. 

We do not know whether our cases of asbestosis 
came from massive exposure during removal of old 
insulation or from many years of exposure by suscep- 
tible individuals during all types of insulation work. 

Summary 

The Long Beach Naval Shipyard has several men on 
disability compensation due to asbestosis; there was one 
death from asbestosis. Many of these employees have 
more than 20 years experience as pipecoverers and in- 
sulators working primarily aboard ship. 



Asbestos exposure during ship overhaul and repair 
varies extensively giving an entirely different problem 
from exposure in mining and manufacturing operations. 
The maximum allowable concentration for pipe cover- 
ing operations or for short duration massive exposures 
is unknown. There still remains a difference of opinion 
among medical authorities on a MAC and the effects 
of long-fiber and short-fiber asbestos. Chest x-ray ex- 
aminations of employees exposed to asbestos can be 
misleading as it usually takes a minimum of seven years 
for cases of asbestosis to develop. Shipboard pipecov- 
ering and insulation during overhaul and repair is a 
hazardous trade. Employees in this trade should wear 
respirators when exposed to dry insulation material 
containing asbestos. 




RESERVE SECTION 



CAPTAIN KENNETH W. SCHENCK MC USNR 

RETIRES AS DIRECTOR OF NAVAL 

RESERVE DIVISION, BUMED 

Ceremonies were held in the Office of the Surgeon 
General on 31 August 1964 honoring CAPT Schenck 
upon his transfer to the Temporary Disability Retired 
List. 

He was cited by RADM R. B. Brown MC USN, 
Acting Surgeon General, for his extreme loyalty to the 
service and patriotism to his country in pursuing a 
career in the Navy and particularly was cited for his 
highly commendable performance during the last two 
years while he served as Director of the Naval Reserve 
Division in the Bureau of Medicine and Surgery. 



CAPTAIN CURTISS CUMMINGS MC USNR 
TO REPORT AS DIRECTOR, 
NAVAL RESERVE DIVISION 

CAPT Curtiss Cummings has recently been ordered 
to active duty to report by 1 November 1964 to the 
Bureau of Medicine and Surgery for duty as Director, 
Naval Reserve Division. CAPT Cummings enrolled in 
Princeton University in 1935 and received an A. B. 
from that school in 1939. He then attended Columbia 
University College of Physicians and Surgeons, and re- 
ceived his degree in medicine in 1943. He has been 
affiliated with the Naval Reserve since his third year as 
a medical student. 

Upon completing an internship at Methodist Hospital, 
Brooklyn, New York, he reported for active duty as a 




CAPTAIN KENNETH W. SCHENCK MC USNR 

Official U. S. Navy Photograph, Navy Photography 
Center, NAS, Anacostia, D. C. 



U.S. NAVY MLDICAL NEWS LETTER 



25 



LT (Junior Grade) Medical Corps, at the Naval Hos- 
pital, St. Albans, Long Island, New York. After a 
brief stay there, LT JG Cummings departed for the 
Amphibious Training Base, Solomon, MD., for duty 
with Landing Crafts Groups under Commander Am- 
phibious Training, Atlantic Fleet. He served as group 
Medical Officer for Commanders LCI (L), Groups 
Seventeen and Fifteen until October 1 945 at which time 
he was ordered to the Receiving Station Naval Base, 
Philadelphia, Pennsylvania, and released to inactive 
duty on 6 November 1945. Dr. Cummings completed 
postgraduate training in medicine and pediatrics at 
Nassau Hospital, Mineola, New York, during 1946-47 



and later affiliated with that hospital. He has been in 
general practice in Nassau County since. He is a mem- 
ber of the Nassau County and New York State Medical 
Societies and serves in the Military Affairs Section of 
the latter. In addition, he holds membership in the 
Reserve Officers Association and the Association of 
Military Surgeons. 

Since his release, Dr. Cummings has continued active 
participation in the Medical Department Reserve Pro- 
gram, his latest position being that of Commanding 
Officer of the Naval Reserve Hospital Corps Division 
3-1, at St. Albans, New York. During this time, he has 
progressively advanced to the rank of Captain, to rank 
from 1 July 1963. 




MISCELLANY 



AMERICAN BOARD OF OBSTETRICS 
AND GYNECOLOGY 



APPLICATIONS FOR 
INSERVICE RESIDENCY TRAINING 1965-1966 



The next scheduled Part I (written) examination of 
this Board will be held at various examining centers in 
the United States, Canada, and military bases outside 
of the continental United States on Friday, December 
11, 1964 at 2:00 P. M. Candidates eligible to take this 
examination will be notified on or about November the 
first where to appear for examination. 

Beginning in 1965, the Part I (written) examination 
will be given early in July. All candidates (including 
new and reopened applicants as well as re-examinees) 
having completed an approved and progressive residency 
program on or before July, 1965 will be eligible to 
request admission to the Part I examination in 1965. 

The 1964 Bulletin containing detailed information on 
the requirements and procedure of application relative 
to the new schedule of examinations beginning in 1965 
is now available for mail distribution. 

Bulletins may be obtained by writing to the office of 
the Secretary, — Clyde L. Randall MD, American Board 
of Obstetrics and Gynecology, 100 Meadow Road, 
Buffalo, New York 14216. Diplomates of this Board 
are requested to inform the Secretary's office of any 
change in address. 



Interested applicants for inservice residency training, 
should carefully review BUMEDINST 1520. 10B for 
information concerning programs offered and procedure 
for submitting applications. 

Deadline for submission for inservice training pro- 
grams to begin in the summer of 1965 is 15 November 
1964. Candidates will be notified of selection or non- 
selection by 15 December 1964. Applications, sub- 
mitted via chain of command, should be for the full 
training program as outlined in BUMEDINST 1520. 
10B. 

Combined programs, such as in Neurosurgery, should 
be requested for the inservice portion first to begin in 
the summer of 1965, with the civilian portion to follow 
in a civilian institution to be determined. 

Applicants are encouraged to list at least three 
choices of naval hospitals for location of training if 
such choices exist in the chosen specialty, and may feel 
free to write the chiefs of services for details of the 
training offered, if desired. 

Early submission of applications is recommended to 
assure processing through chain of command and re- 
ceipt in BuMed prior to the 15 November 1964 dead- 
line. — Training Branch, Professional Division, BuMed. 



26 



U.S. NAVY MEDICAL NEWS LETTER 



THE COMPLETE NIGHTMARE 

Memories. Some of them pleasant, if intangible. Re- 
called to us by little things — the smell of pineapple on 
an offshore breeze, the glint of sunlight on a calm sea, 
the taste of salt spray on the air . . . 

Some are preserved in mementos. Souvenirs of voy- 
ages past. Photographs. Personal memories: the stuff 
of which a life is made. And there are official mem- 
ories, the stuff of which history is made. Libraries, 
neatly ordered files, archives. 

And there are other official memories — the stuff of 
which nightmares are made. Strewn about every ship 
and station, packed into every available nook and 
cranny: the remains of Paperwork Past. Not a dimly 
remembered ghost, but an ever-present bulk of outdated 
publications, instructions, check-off lists of check-off 
lists. 

Is it nostalgia for World War II aircraft that keeps 
the old recognition manuals around? Is it a sense of 
"continuity with the past" that makes some ships hang 
onto OpOrders for exercises long since ended? Is it 
insecurity that makes some ships preserve a three-foot 
high stack of old admin and ORI inspection lists and 
forms? 

More than likely, it is an unwillingness to discrimi- 
nate between what is useful, and what may, under some 
improbable set of circumstances, be useful. Or the 
nagging fear that some check-off list will call upon the 
command to produce a complete set of repair manuals 
for all equipment removed from the ship within the last 
fen years. 

And the problem rests not so much with each indi- 
vidual command, as it does with a system that, over the 
years, has come to lead us into such a way of thinking. 
A system that has never been denned or organized, but 
has grown unaided and uncoordinated. A system based 
on suspicion; a system that does not accept "results" as 
proof of accomplishment but requires excessive and op- 
pressive documentation of each step along the way. A 
system that has become a monster: the paperwork 
monster, that today threatens to devour the very thing 
it was created to protect — the combat readiness of the 
Fleet. 

But now, we have a solution. Or, rather, a way to 
find the thousand solutions that are needed. It is called 
Project SCRAP — the Selective Curtailment of Reports 
and Paperwork. Conceived by Under Secretary of the 
Navy Paul B. Fay, it is headed by the Naval Inspector 
General and is fully supported by the Secretary of the 
Navy and the Chief of Naval Operations. So fully 
supported, in fact, that it has been given a special 
"SECNAV Designated Project" status. This puts it in 
the same league as the POLARIS program and the 
Surface Missile System program, the only other so des- 
ignated projects in the Navy. What is boils down to is 
this: we are cutting the red tape on a project specifically 
created to cut the red tape. 



SCRAP has one primary goal. To improve combat 
readiness by the "prompt reduction of paperwork in the 
operating forces to that required by a need to know or 
need to act." And by "the identification and elimination 
of least essential administrative practices and the de- 
velopment of policies and procedures which will effec- 
tively monitor and control the flow of paperwork on a 
permanent basis." At the same time that readiness is 
being increased, it is obvious that there are also going 
to be large savings in money and manpower. 

SCRAP is not going to choke off those paperwork 
procedures that are necessary to orderly and efficient 
administration or operations, not set every command 
adrift without guidelines or guidance. "Selective Cur- 
tailment" are the important words. 

And, while SCRAP is being coordinated at the high- 
est levels of the Navy, it needs the interest and coop- 
eration of every man and woman — officer, enlisted and 
civilian — connected with the Navy. And it is seeking 
ideas, comments, suggestions — official and unofficial — 
from every one of them — about every phase of paper- 
work: logs, reports, books, files, manuals, newspapers, 
plans, orders, procedures, instructions, notices. The 
monster to be found on every ship and station that is 
crowding men and equipment off the ships with sheer 
bulk; the care and feeding of which are crowding the 
useful working hours out of the day. 

You will be hearing a lot about SCRAP in the months 
to come, You may not read too much about it, though 
— NAVNEWS is one project that will be conducted 
"with a minimum of paperwork." And SCRAP would 
like to be hearing from you. Help prevent the memories 
of today from becoming the nightmares of tomorrow. 
—NAVNEWS 15 July 1964. 

ASSOCIATION OF MILITARY SURGEONS 
TO CONVENE OCTOBER 20-22 

Washington, D. C. Modern man's changing living 
environment — from capsules on the bottom of the sea 
to capsules floating in space — will draw the attention of 
the nation's top scientific and medical personnel during 
the 71st Annual Meeting of the Association of Military 
Surgeons of the United States scheduled for October 20 
thru 22, 1964 in Washington, D. C. The theme of the 
Meeting is "Military Progress Through Scientific 
Achievement". 

Registration for the Meeting, which will be held at 
the Sheraton-Park Hotel, begins on October 19. Gen- 
eral Chairman of the event is Brigadier General Joe M. 
Blumberg MC USA, Director of the Armed Forces 
Institute of Pathology in Washington. 

Association President, Col Robert C. Kimberly MC, 
Maryland Army National Guard, will preside at the 
opening session of the meeting. The keynoter is Dr. 
Robert M. Zollinger, of the University Hospital, Colum- 
bus, Ohio and President of the Society of Medical Con- 
sultants to the Armed Forces. Also speaking during 
the opening sessions will be Lt Gen Lewis B. Hershey, 



U.S. NAVY MEDICAL NEWS LETTER 



27 



Director, Selective Service System; Dr. Shirley C. Fisk, 
Deputy Assistant Secretary of Defense; Lt Gen Leonard 
D. Heaton, Surgeon General, USA; RADM Edward C. 
Kenney, Surgeon General, USN; Maj Gen Richard L. 
Bohannon, Surgeon General, USAF; Dr. Luther L. 
Terry, Surgeon General, USPHS; and Dr. Joseph H. 
McNinch, Chief Medical Director of the VA. 

The following topics will be presented and discussed: 
(1) symposium on progress in medicine in relation to 
environmental challenges created by man's exploration 
of the unknown; (2) clinical studies on acute mountain 
sickness; (3) psychological aspects of Antarctic living. 
Another feature of the symposium will be a presentation 
on manned underwater habitations by CAPT G. F. 
Bond of the U. S. Naval Medical Research Laboratory 
at the New London, Conn, Submarine Medical Center. 
Awards for the most outstanding contributions to 
military medicine will be presented in ceremonies sched- 
uled for October 21. Among the prizes to be awarded 
are: The Andrew Craigie Award, Federal Nursing Serv- 
ice Award, Founder's Medal, Gorgas Medal, John Shaw 
Billings Award, Major Louis Livingston Seaman Prize, 
McLester Award, Sir Henry Wellcome Medal and Prize, 
Stitt Award and the Sustaining Membership Award. 

Following the Awards, Dr. Edward R. Annis, im- 
mediate past-president of the AMA, will give the Sus- 
taining Membership lecture. His address will be titled 
"The World's Greatest Arsenal." 

Meetings of the various sections of the Association 
will be held October 21. Holding their annual meetings 
in separate sessions during the convention will be the 
sections on dentistry, veterinary medicine, pharmacy, 
Medical Service Corps, Nurse Corps and Medical Spe- 
cialist Corps. Each section will hold scientific sessions 
and annual business meetings. 

Medical problems caused by the increasing military 
involvement in the Far East will be discussed by a panel 
of experts during a symposium scheduled for the final 
day of the convention. Symposium speakers will discuss 
infectious hepatitis in Korea, leptospirosis in Malay and 
new developments in malaria research. Moderator will 
be Col W. D. Tigertt MC USA, Commandant and 
Director of the Walter Reed Army Institute of Research. 
Another panel discussion of importance to the medi- 
cal and pharmaceutical world is scheduled for the Sus- 
taining Members' meeting. All members of the Intra- 
Governmental Procurement Advisory Council on Drugs 
(IPAD) will present views and answer questions from 
the audience. 

Also included in the convention program is a broad 
study of medical advances resulting from developments 
in modern weaponry. During the session papers will be 
presented on subjects ranging from nutrition for na- 
tional defense to a bioastronautic report on X-15 flights. 
Toxicologic aspects of missiles and nuclear submarine 
warfare, dynamic function testing in aerospace crew- 
men and naval medical research in relation to seapower 
will also be discussed. 



Other highlights during the scientific sessions include 
a study of the medical aspects of operations of the Army 
Special Forces and a survey of inter-agency and inter- 
governmental cooperation in the investigation of aircraft 
accidents. 

A full schedule of social events for the ladies, includ- 
ing guided tours of the Washington area, and a fashion 
show and luncheon is also on the program. 

The convention will officially close on the afternoon 
of the last day with the annual business meeting of the 
Association, followed in the evening by the annual 
banquet held in recognition of the International Dele- 
gates and the award winners and their sponsors. 

Organized in 1891 and incorporated by Congress in 
1903, the Association now has some 6,000 members. 
Membership is drawn from the medical services of the 
U. S. Armed Forces and their medical Reserves, the 
U. S. Public Health Service, the Veterans Administra- 
tion, the National Guard of the various States, and the 
military services of other nations. 

Annual Dinner reservations for the convention should 
be made by September 20 with the Association of Mil- 
itary Surgeons of the U. S., 1500 Massachusetts Avenue, 
N. W., Washingon, D. C. 20005. 



ANNUAL MEETING OF THE 
AMERICAN PUBLIC HEALTH ASSN. 

Progress and problems in man's global war against 
disease will be discussed by authorities from this coun- 
try and abroad during the Association's 92nd annual 
meeting in New York City, October 5-9. 

The New York Hilton will be headquarters for the 
meeting, but some scientific sessions will be combined 
with field trips "to give public health workers a unique 
opportunity to explore the many pioneering programs 
now underway in New York and the metropolitan area," 
according to Dr. Berwyn F. Mattison, executive director 
of the Association. 

Highlights of the sessions will include presentation of 
major annual awards in public health — the fourth annu- 
al Bronfman Prizes for Public Health Achievement, 
established by the Association with a grant from the 
Samuel Bronfman Foundation, Inc., to honor "outstand- 
ing current creative work leading directly to improved 
health for large numbers of people," and the Sedgwick 
Memorial Medal for distinguished service to public 
health. 

The program for the APHA sessions, Dr. Mattison 
said, will include presentation of scientific papers cov- 
ering latest research and program developments in the 
fields of specialization covered by the Association's four- 
teen sections — dental health, engineering and sanitation, 
epidemiology, food and nutrition, health officers, lab- 
oratory, maternal and child health, medical care, mental 
health, occupational health, public health education, 
public health nursing, school health and statistics. 



28 



U.S. NAVY MEDICAL NEWS LETTER 



Population problems and poverty and health are the 
subjects of two general sessions. 

The American Public Health Association, with head- 
quarters at 1790 Broadway, New York 19, is the largest 
professional society of public health personnel in the 
Western Hemisphere, with more than 14,000 members. 
Officers, in addition to Dr. Mattison, are president, 
Dr. John D. Porterfield, statewide coordinator of health 
and medical affairs at the University of California, 
Berkeley, and former Deputy Surgeon General of the 



U. S. Public Health Service; president-elect, Dwight F. 
Metzler of Lawrence, Kansas, executive secretary of the 
Kansas State Water Resources Board; immediate past 
president, Dr. J. W. R. Norton, state health director of 
North Carolina; treasurer, Dr. D. John Lauer, medical 
director of International Telephone and Telegraph Cor- 
poration, New York; speaker of the council, Dr. Leroy 
E. Burney, vice president of Temple University, Phila- 
delphia, and former Surgeon General, U. S. Public 
Health Service; and chairman of the executive board, 
Dr. Wilson T. Sowder, state health officer of Florida. 



Health aspects of Metropolitan Planning. Most coun- 
tries today are faced with problems created by popula- 
tion growth and the rapidly increasing concentration of 
people, production, and services in towns, cities, and 
metropolitan areas. For public health agencies, these 
problems — and especially those relating to environ- 
mental health are proving to be highly complex in 
variety and scope, and difficult of solution. They in- 
clude inadequate water supplies and waste disposal fa- 
cilities, unhygienic and badly sited housing, air and 
water pollution. 

A WHO Expert Committee on Health and Sanitary 
Aspects of Metropolitan Planning, Housing and Indus- 
trialization met in Geneva from 23 to 29 June 1964. 
Among the topics discussed were planning criteria and 
tools, housing, open and recreational areas, water sup- 
ply, waste disposal and drainage, air pollution, the con- 
trol of radiation, and vector control. Political, social, 
economic, and legal factors were also discussed. — WHO 
Chronicle 18(7): 274, July 1964. 

Relatively little attention has been paid to the health 
hazards that may arise from the increasing introduction 
of synthetic organic chemicals — new plastics and plas- 
ticizers, detergents and solvents, additives to foods, 
fuels, or alloys, and pesticides — into the human en- 
vironment, and particularly into surface and under- 
ground water supplies. WHO is now laying the foun- 
dations for a programme that may eventually lead to 
the establishment of permissible levels for chemical 
contaminants.— WHO Chronicle 18(4): 141, April 
1964. 

Teaching of Nursing in British Honduras. The Govern- 
ment of British Honduras and the Pan American Sani- 
tary Bureau (PASB), which acts as the WHO Regional 
Office for the Americas, are co-operating in a project 
for the improvement of nursing education. In addition 
to revision of the basic curriculum of the School of 
Nursing in Belize, the project will include a general 
study of nursing needs and staffing. 

PASB will cover the cost of laboratory equipment 
and teaching material, award fellowships for the train- 



ing of nursing staff abroad, and provide a nursing con- 
sultant. Local expenses will be covered by the Gov- 
ernment of British Honduras. — WHO Chronicle 18(7): 
274, July 1964. 

Conservation Workers Leptospirosis Target. Conserva- 
tion work in Missouri has been added to the category of 
jobs in which leptospirosis is a hazard as a result of 
studies reported by Dr. Herbert S. Goldberg, professor 
of microbiology, Dr. D. C. Blenden, assistant professor 
of veterinarian bacteriology, and Dr. J. T. Logue, clin- 
ical assistant professor of medicine, University of 
Missouri. 

Eighty-one blood samples taken from personnel of 
the Missouri Conservation Commission showed a rate 
of infection that was as high if not higher than the rate 
for veterinarians, farmers, packinghouse workers, and 
meat inspectors. 

Irradiated Foods. The use of ionizing radiation for the 
preservation of food for human consumption has been 
under development for some years, and in a few 
countries the process is being tried out on a small scale. 

The health aspects of this method of preservation 
were discussed by a joint FAO/IAEA/WHO Expert 
Committee on the Technical Basis for Legislation on 
Irradiated Foods, which met in Rome from 21 to 28 
April 1964. The Committee considered the possible 
hazards to consumers that might result from irradiation 
of the foods themselves and also from the influence of 
ionizing radiation on the micro-organisms present in the 
foods. 

The Committee advised on special requirements for 
testing the wholesomeness of irradiated foods in order 
to provide a common technical basis for the drafting of 
legislation.— WHO Chronicle 18(6): 230, June 1964. 
It is still commonly thought that to have had a heart 
attack or to be suffering from any cardiovascular dis- 
order is to be mortally ill. In actual fact it is becoming 
increasingly possible to halt, reverse, or cure specific 
cardiac impairments. — WHO Chronicle 18 (6): 216, 
July 1964. 



U.S. NAVY MEDICAL NEWS LETTER 



29 



Inquiry Into Home Accidents. Accidents are today the 
leading cause of death among children and young adults 
in many developed countries. The majority of accidents, 
it is believed, occur in the home. In the Netherlands, 
for example, more than half of all accidents to females 
are home accidents. Unfortunately, information on 
such accidents is in general scarce, and studies of their 
immediate causes are still rudimentary. 

As part of a programme to obtain knowledge about 
accidents of this type with a view to their prevention, a 
Meeting on the Epidemiology of Home Accidents was 
held in Copenhagen by the WHO Regional Office for 
Europe from 17 to 20 March 1964. 

The participants were epidemiologists, statisticians, 
and public health administrators, engaged in epidemio- 
logical studies of home accidents or in preventive work 
based on such studies. Invitations were limited to 
countries in which deaths caused by accidents (other 
than those involving transport) are tabulated by place 
of occurrence.— WHO Chronicle 18(6): June 1964. 



Schools of Public Health in Latin America. At the in- 
vitation of the Government of Brazil, the Pan American 
Sanitary Bureau (PASB), which acts as the WHO Re- 
gional Office for the Americas, held the Third Confer- 
ence of Deans of Schools of Public Health in Latin 
America, at Sierra Negra, Sao Paulo, Brazil, from 22 to 
28 September 1963. The main aim of the Conference 
was to study the teaching of health administration in 
the schools and its inter-relation with the social and 
behavioural sciences. Questions of educational method 
and public health planning were also discussed. The 
Conference was attended by 25 participants from Ar- 
gentina, Brazil, Colombia, Chile, Mexico, Venezuela, 
and Puerto Rico, and six observers from various educa- 
tional institutes in the Americas, as well as members of 
the PASB staff. The two earlier conferences in the 
series were held in Mexico in 1959 and in Venezuela in 
1961.— WHO Chronicle 18(6): 232, June 1964. 



DEPARTMENT OF THE NAVY 

U. S. NAVAL MEDICAL SCHOOL 

NATIONAL NAVAL MEDICAL CENTER 

BETHESDA. MARYLAND 20014 

OFFICIAL BUSINESS 

PERMIT NO. 1048 



POSTAGE AND FEES PAID 
NAVY DEPARTMENT 



30 



U.S. NAVY MEDICAL NEWS LETTER